Lead Utilization Review - RN

Personify Health, Inc.; United States; Remote; USD 52,000 - 61,000; Full time

Benefits offered by this job

Competitive benefits

Paid Time Off

Mental health support

Retirement planning

Professional development

Job summary

Personify Health, Inc. seeks a RN UM Team Lead to coach reviewers, apply medical-necessity criteria, and keep documentation audit-ready for timely and compliant care decisions.

Schedule: Mon–Fri 8:00 AM–5:00 PM Pacific Time with rotating Saturday coverage; lead a team focused on reducing backlog while protecting member data and maintaining HIPAA standards. You’ll partner with providers, facilities, case management, appeals, and provider relations to move determinations and keep care moving.

Qualifications

• Active RN license.
• Experience in utilization management, clinical review, or case management.
• Background applying medical-necessity criteria and benefit plan interpretation in a healthcare payer or clinical review setting.

Responsibilities

• Set daily direction for your UM team and establish priorities.
• Coach reviewers on medical-necessity criteria and policy interpretation.
• Monitor workflow health, aging cases, and turnaround risk; flag barriers with a recommendation.
• Audit documentation quality for completeness and regulatory timeliness.
• Build reviewer capability with shadowing plans, job aids, and training.
• Resolve cross-team barriers with providers, facilities, Case Management, Appeals, and Provider Relations to keep determinations moving.
• Protect member data and HIPAA compliance; model ethical decision-making.
• Drive training completion and attestations on time.

Skills

UM platforms

Medical terminology

Remote collaboration tools

Education

Active RN license

Job description

Overview

Who We Are

Because health is personal. That's why Personify Health created the first and only personalized health platform—bringing health plan administration, holistic wellbeing solutions, and comprehensive care navigation together in one place. We serve employers, health plans, and health systems with data-driven solutions that reduce costs while actually improving health outcomes. Together, our team is on a mission to empower people to lead healthier lives.

Learn even more about the work that drives us at personifyhealth.com.

Responsibilities

Ready to lead the clinical team that keeps care moving when it matters most?

Why This Role Matters

Every delayed or unclear coverage decision is a person waiting on care they need. The RN UM Team Lead makes sure that doesn't happen — coaching reviewers to apply medical-necessity criteria consistently, catching risk before it becomes a backlog, and keeping documentation audit-ready so decisions hold up under scrutiny. This isn't a background role: it's the difference between a member getting a timely answer and getting stuck in a queue. You're the person providers and internal teams turn to when a case gets complicated and needs a clear path forward. When your team runs tight, members get faster answers, providers get fewer headaches, and the business stays compliant — that's the job.

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

What You’ll Actually Do

• Set daily direction for your UM team: Establish priorities, reinforce expectations, and build a culture where clinical quality and accountability are the norm, not the exception.


• Coach reviewers on criteria application: Guide consistent use of medical-necessity criteria, medical policy, and benefit language, and step in with real-time answers when interpretations vary.


• Monitor workflow health daily: Track intake volume, aging cases, and turnaround risk; flag barriers to the UM Manager with a recommendation attached, not just a problem.


• Audit for documentation quality: Review reviewer work for completeness and audit readiness, then coach for sharper clinical rationale and tighter regulatory timeliness.


• Build reviewer capability: Run shadowing plans, job aids, and competency check-ins for new and existing staff; identify training gaps and propose solutions before they become bigger problems.


• Resolve cross-team barriers: Partner with providers, facilities, Case Management, Appeals, and Provider Relations to clear roadblocks and keep determinations moving.


• Protect member and company data: Maintain HIPAA compliance and company privacy standards, and model the ethical decision-making you expect from your team.


• Drive training completion: Complete required training and attestations on time, and keep your team on track to do the same.

Qualifications

What You Bring to Our Team

Education & Experience:

• Active RN license


• Experience in utilization management, clinical review, or case management


• Background applying medical-necessity criteria and benefit plan interpretation in a healthcare payer or clinical review setting

Technical Skills:

• Proficiency with UM platforms and standard office/productivity tools


• Working knowledge of medical terminology and coding concepts (ICD-10, CPT, HCPCS) sufficient to support accurate UM documentation


• Familiarity with remote collaboration tools for team visibility and responsiveness

Benefits

The Highlights:

• 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? Visitpersonifyhealthbenefits.comto explore our complete benefits package, wellness programs, and other employee perks.

Compensation: This position offers a base salary range of $38-$44 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.