Utilization Review Nurse - RN

Responsibilities

Congratulations, you've just landed a role at Personify Health! Here’s what you can expect:

• Evaluate requested services against benefit language, medical policy, and nationally recognized criteria (MCG, NCCN) to determine the appropriate level of care.
• Escalate non-certifications with precision: Route cases that don’t meet criteria to the Medical Director for secondary clinical review.
• 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.
• Manage a caseload by urgency, regulatory deadline, and member impact, and flag barriers early so determinations stay timely and compliant.
• Confirm eligibility, benefits, authorization, and network status to steer members toward in-network, benefit-compliant options when clinically appropriate.
• Prepare clinical summaries and documentation, coordinate peer-to-peer discussions with physicians, and route appeals (including IRO referrals) accurately and on time.
• 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.
• Maintain HIPAA compliance and confidentiality using minimum-necessary standards, and stay current on required training and annual competencies.

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.

Schedule

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

Pay

This position offers a base salary range of $30.00-$38.00 per hour, depending on location, skills, and experience.