Hiring: Utilization Review Nurse - RN Company: Personify Health Location: United States Job Posted Time: 2026-09-16 23:36:26 Target Skills & Keywords : CPT, HIPAA, ICD-10, Microsoft Excel, REST, Utilization Review About the job Experience: •1-2+ years of recent clinical experience (acute care, med-surg, ICU/ED, or similar setting) •Utilization review/utilization management experience preferred Required Skills: •Ready to turn clinical expertise into life-changing decisions, one review at a time? •Schedule: Monday–Friday, 8:00 AM–5:00 PM Pacific Time, with rotating Saturday coverage as required. •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. •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. Qualifications: •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. •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) Compensation: •Comprehensive medical and dental through our own health solutions (yes, we use what we build) Interested candidates, please apply directly through the job posting on company's career page or try via AI auto apply on this platform. Don't miss this opportunity to join a forward-thinking team!