Utilization Review Nurse, RN, Remote Anywhere

2025-4201 Overview Now is the time to join us! Ready to create a healthier world? We are ready for you! Personify Health is on a mission to simplify and personalize the health experience to improve health and reduce costs for companies and their people. At Personify Health, we believe in offering total rewards, flexible opportunities, and a diverse inclusive community, where every voice matters. Together, we’re shaping a healthier, more engaged future. Responsibilities Who are you? We are seeking a Utilization Review Nurse to join our dynamic team. This role requires weekend availability, and flexible scheduling to support a healthy work-life balance. In this role you will wear many hats, but your knowledge will be essential in the following: • Under the supervision of a registered nurse (RN), provide professional assessment and review for the medical necessity of treatment requests and plans. • Provide first level review for all outpatient and ancillary pre-certification requests for medical appropriateness; all inpatient hospital stays including mental health, substance abuse, skilled nursing and rehabilitation for medical necessity; and all post claim or post service reviews. • Ensure proper referral to medical director for denial authorizations through independent review organizations (IRO). • Work with hospital staff to prepare patients for discharge and ensure a smooth transition to the next level of care. • Refer requests that fall outside of established guidelines to advance review or senior care consultants. • Process appeals for non-certification of services; complete non-certification letters when appropriate. • Review plan document for benefit determinations; attempt to redirect providers and patients to PPO providers. • Identify and refer potential cases to case management, wellness, chronic disease and Nurturing Together program. • Complete documentation for all reviews in Eldorado/Episodes; maintain confidentiality. • Utilize MCG guidelines, medical policies, Medscape, and NCCN. • Ability to meet productivity, quality, and turnaround times daily. You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in. Qualifications What you bring to the Personify Health team: In order to represent the best of what we have to offer you come to us with a multitude of positive attributes including: • Current RN license in the United States or U.S. territory. • 1+ years of clinical experience required. You also take pride in offering the following Core Skills, Competencies, and Characteristics: • Knowledge of medical claims and ICD-10, CPT, HCPCS coding. • Proficiency in software applications including, but not limited to, Microsoft Word, Microsoft Excel, Microsoft PowerPoint and Outlook • Excellent verbal and written communication skills • Ability to speak clearly and convey complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others. No candidate will meet every single desired qualification. If your experience looks a little different from what we’ve identified and you think you can bring value to the role, we’d love to learn more about you! Personify Health is an equal opportunity organization and is committed to diversity, inclusion, equity, and social justice. In compliance with all states and cities that require transparency of pay, the base compensation for this position ranges from $32 to $38 per hour. Note that compensation may vary based on location, skills, and experience. This position is eligible for health, dental, vision, mental health and other benefits. We strive to cultivate a work environment where differences are celebrated, and employees of all backgrounds are empowered to thrive. Personify Health is committed to driving Diversity, Equity, Inclusion and Belonging (DEIB) for all stakeholders: employees (at each organization level), members, clients and the communities in which we operate. Diversity is core to who we are and critical to our work in health and wellbeing. #WeAreHiring #PersonifyHealth #TPA #HPA #Selffunded Beware of Hiring Scams: Personify Health will never ask for payment or sensitive personal information such as social security numbers during the hiring process. All official communication will come from a verified company email address. If you receive suspicious requests or communications, please report them to [email protected]. All of our legitimate openings can be found on the Personify Health Career Site. Application Deadline: Open until position is filled. Apply tot his job Apply tot his job