[Hiring] Utilization Review Nurse @Personify Health

Role Description

Ready to turn clinical expertise into life-changing decisions, one review at a time?

Every determination you make decides whether a member gets the care they need, when they need it. This role sits at the exact point where clinical judgment meets real-world impact, translating evidence-based criteria into decisions that protect members and keep the organization compliant, efficient, and trusted. Get it right, and members move forward with the right care in the right setting, network partners stay strong, and the organization avoids costly, avoidable risk. Get it wrong, or get it slow, and everyone feels it, from the member waiting on an answer to the Medical Director who depends on a clean, well-documented case. Your reviews are the front line of quality, and your accuracy is what turns a good UM program into a great one.

Schedule: Monday–Friday, 8:00 AM–5:00 PM Pacific Time, with rotating Saturday coverage as required.

What You'll Actually Do

• Conduct medical-necessity reviews:
  • Evaluate requested services against benefit language, medical policy, and nationally recognized criteria (MCG, NCCN) to determine the appropriate level of care, applying state and federal requirements at every step.
• Escalate non-certifications with precision:
  • Route cases that don't meet criteria to the Medical Director for secondary clinical review, ensuring every adverse determination is timely, defensible, and aligned with NCQA/URAC accreditation standards.
• Dig into the clinical record:
  • Analyze documentation for completeness, flag acuity and risk indicators, catch inconsistencies or gaps, and act fast with outreach or escalation when something doesn't add up.
• Prioritize with purpose:
  • Manage a caseload by urgency, regulatory deadline, and member impact, and flag barriers early so determinations stay timely and compliant.
• Redirect care in-network:
  • Confirm eligibility, benefits, authorization, and network status to steer members toward in-network, benefit-compliant options when clinically appropriate.
• Build the appeals case:
  • Prepare clinical summaries and documentation, coordinate peer-to-peer discussions with physicians, and route appeals (including IRO referrals) accurately and on time.
• Document with rigor:
  • Capture every review, rationale, criteria citation, and outcome in UM systems in real time, creating a clean audit trail that supports quality oversight and reporting.
• Hit the bar, every time:
  • Meet productivity, quality, accuracy, and turnaround standards, participate in calibration activities, and put feedback into action immediately.
• Protect what matters:
  • Maintain HIPAA compliance and confidentiality using minimum-necessary standards, and stay current on required training and annual competencies.
• Show up for the team:
  • Cross-train and flex into coverage roles as needed, keeping operations running and service commitments met.

Qualifications

• Current, unrestricted RN license in the United States or a U.S. territory (compact license accepted where applicable)
• Graduate of an accredited nursing program (ADN or diploma required; BSN preferred)
• 1-2+ years of recent clinical experience (acute care, med-surg, ICU/ED, or similar setting)
• Utilization review/utilization management experience preferred
• Proficiency with Microsoft Word, Excel, and Outlook
• Working knowledge of ICD-10, CPT, and HCPCS coding and medical claims
• Ability to interpret medical records and apply evidence-based criteria and plan medical policies
• Comfort working across multiple screens and systems with strong typing proficiency
• Ability to work independently within UM platforms and workflows after training

Benefits

• Competitive base salary and benefits effective day one
• Comprehensive medical and dental through our own health solutions (yes, we use what we build)
• Paid Time Off—rest and recharge time is non-negotiable
• Mental health support, retirement planning, and financial protection
• Professional development with clear career progression and learning budgets
• Mission-driven culture where diverse perspectives drive real impact on people's health

Company Description

Personify Health is an equal opportunity employer committed to diversity, equity, inclusion, and belonging. We cultivate a work environment where differences are celebrated, and employees of all backgrounds are empowered to thrive—because diversity is core to who we are and critical to our work in health and wellbeing.