Utilization Review Nurse RN Part-Time

Personify Health brings health plan administration, holistic wellbeing solutions, and comprehensive care navigation together in one personalized health platform. We serve employers, health plans, and health systems with data-driven solutions that reduce costs while improving health outcomes, empowering people to lead healthier lives.

Responsibilities

• Perform utilization management (UM) medical-necessity reviews and level-of-care determinations for requested services using the organization’s hierarchy of guidance (benefit language/plan documents, medical policies, nationally recognized evidence-based criteria such as MCG; NCCN as applicable) and applicable state/federal requirements.
• Apply criteria and policy consistently; when a request does not meet criteria, route timely to the Medical Director for secondary clinical review and potential adverse determination in accordance with UM policies and accreditation standards (e.g., NCQA/URAC, as applicable).
• Use critical thinking to analyze clinical documentation for completeness, identify key risk/acuity indicators, recognize inconsistencies or missing information, and initiate timely outreach/escalation per UM workflow.
• Apply strategic thinking within established guidelines by prioritizing workload based on urgency, regulatory/accreditation time frames, and potential member impact; communicate barriers early to support timely, compliant determinations.
• Assist with in-network and benefit-compliant redirection when clinically appropriate by confirming eligibility, benefits, authorization requirements, and network status.
• Support the appeals process by preparing clinical summaries and documentation; coordinating peer-to-peer/MD discussions when indicated; and ensuring timely routing/escalation per policy (including Independent Review Organization (IRO) processes when required).
• Document reviews, rationale, criteria/policy citations, communications, and outcomes accurately and contemporaneously in designated UM systems to support quality oversight, reporting, and audit readiness.
• Meet established productivity, quality, accuracy, and turnaround-time standards; participate in calibration/quality activities; and incorporate feedback into daily practice.
• Maintain HIPAA compliance and confidentiality using minimum-necessary standards; complete required training and annual competencies within established deadlines.
• Cross-train and provide cross-coverage as needed to support team operations and service-level commitments.

Requirements

• Current, unrestricted RN license in the United States or 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 (e.g., acute care, med-surg, ICU/ED, or other relevant setting).
• Prior utilization review/utilization management experience preferred.
• Ability to interpret medical records and apply evidence-based criteria and plan medical policies with appropriate escalation to Medical Director for non-certifications.
• Basic computer literacy, ability to work on multiple screens, and proficient typing skills.
• Proficiency in software applications including Microsoft Word, Microsoft Excel, and Outlook.
• Excellent verbal and written communication skills for conveying and interpreting complex or technical information.
• Ability to work independently and utilize written resources to problem solve.
• Knowledge of medical claims and ICD-10, CPT, HCPCS coding.

Physical and Mental Requirements

• Ability to perform the essential job functions safely and successfully with or without reasonable accommodation, including meeting qualitative and/or quantitative productivity standards.
• Ability to maintain regular, punctual attendance.
• Ability to sit for 6-8 hours.
• Constant use of computer keyboard and mouse; repetitive use of both hands.
• Occasional to frequent twisting of neck; occasional bending of neck and at waist.

Benefits

• Competitive base salary and benefits effective day one.
• Comprehensive medical and dental through Personify Health’s own health solutions.
• 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.

Visit personifyhealthbenefits.com to explore the complete benefits package, wellness programs, and other employee perks.

Pay

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

Schedule

Part-time, up to 28 hours per week with weekends required.