Utilization Management Nurse RN

• →Decide with clinical rigor: Perform medical-necessity reviews and level-of-care determinations using benefit language, plan documents, medical policies, and nationally recognized evidence-based criteria such as MCG (and NCCN as applicable), in line with state and federal requirements.
• →Apply criteria consistently: Hold to policy every time, and when a request doesn’t meet criteria, route it promptly to the Medical Director for secondary clinical review and potential adverse determination per UM policy and accreditation standards.
• →Dig into the documentation: Analyze clinical records for completeness, spot risk and acuity indicators, flag inconsistencies or missing information, and start outreach or escalation right away per UM workflow.
• →Prioritize what can’t wait: Organize your workload around urgency, regulatory and accreditation time frames, and potential member impact, and raise barriers early so determinations stay timely and compliant.
• →Steer care in-network: Confirm eligibility, benefits, authorization requirements, and network status to support benefit-compliant redirection when it’s clinically appropriate.
• →Power the appeals process: Prepare clinical summaries and supporting documentation, coordinate peer-to-peer and Medical Director discussions when indicated, and route cases on time per policy, including Independent Review Organization (IRO) processes when required.
• →Document with precision: Record reviews, rationale, criteria and policy citations, communications, and outcomes accurately and in real time in designated UM systems to support quality oversight, reporting, and audit readiness.
• →Hit the standard: Meet productivity, quality, accuracy, and turnaround-time expectations, take part in calibration and quality activities, and put feedback to work in your daily practice.
• →Protect member privacy: Maintain HIPAA compliance and confidentiality using minimum-necessary standards, and complete required training and annual competencies by their deadlines.
• →Back up the team: Cross-train and provide cross-coverage to keep operations running and service-level commitments met.

• Current, unrestricted RN license in the United States or a U.S. territory (compact license acceptable where applicable)
• Graduate of an accredited nursing program (ADN or diploma required; BSN preferred)
• Minimum 1–2 years of recent clinical experience in acute care, med-surg, ICU/ED, or another relevant setting
• Prior utilization review or utilization management experience preferred

• Ability to interpret medical records and apply evidence-based criteria and plan medical policies, with appropriate escalation to the Medical Director for non-certifications
• Working knowledge of MCG, NCCN (as applicable), NCQA and URAC standards, and HIPAA requirements
• Knowledge of medical claims and ICD-10, CPT, and HCPCS coding
• Proficiency in Microsoft Word, Excel, and Outlook
• Basic computer literacy, proficient typing, and the ability to work across multiple screens
• Ability to work independently within UM systems and programs after training

• 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

Want the full picture? Visit personifyhealthbenefits.com to explore our complete benefits package, wellness programs, and other employee perks.

Compensation: This position offers a base salary range of $35.00-$38.00 per hour, depending on location, skills, and experience. You're eligible for our full benefits package starting day one.

Our Commitment: 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.

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