Lead Utilization Review - RN

Santa Barbara Cottage Hospital; United States; On-site; USD 52,348 - 59,236; Full time

Benefits offered by this job

Comprehensive medical and dental benefits

Paid Time Off

Mental health support

Professional development opportunities

Job summary

Join Personify Health as an RN Utilization Management Team Lead, where you will provide clinical and operational leadership in a dynamic environment. With a strong emphasis on compliance and quality, you will support timely coverage determinations and enhance team performance through coaching.

The ideal candidate will have RN Licensure, extensive clinical experience, and proficiency in medical coding. This position offers a competitive salary range of $38-$43 per hour, comprehensive benefits, and a mission-driven work culture.

Qualifications

• Ability to critically evaluate claims data and determine treatment plan.
• Excellent verbal and written communication skills.
• Ability to speak clearly and convey complex information.

Responsibilities

• Provide clinical and operational leadership for UM.
• Coach reviewers on medical necessity criteria application.
• Monitor workflow health and coordinate coverage plans.

Skills

Knowledge of medical claims and coding

Excellent interpersonal and communication skills

Strong customer orientation

Time management skills

Highly organized

Education

RN Licensure

Licensed in the state of California preferred

5+ years combined clinical experience

> 2 years utilization review experience

Tools

Microsoft Word

Microsoft Excel

Microsoft PowerPoint

Outlook

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

What You’ll Actually Do

POSITION SUMMARY:

The RN Utilization Management (UM) Team Lead provides clinical and operational leadership to support timely, and evidence-based coverage determinations. This role leads day‑to‑day UM execution through coaching and development and auditing of clinical reviewers, quality oversight, case escalation support, and partnership with internal and external stakeholders to promote appropriate level of care and smooth transitions. The Team Lead reinforces compliance with applicable regulatory, contractual, and accreditation requirements, supports audit readiness and consistency in decision‑making, and contributes to continuous improvement of UM workflows and member/provider experience.

This Candidate will have to work between PST hours Required

ESSENTIAL DUTIES & RESPONSIBILITIES (BY LEVEL)

Level 1 (UM RN Reviewer / Team Lead I)

• Serve as a visible first‑line leader for assigned UM staff by setting daily priorities, reinforcing expectations, and promoting a culture of clinical quality, accountability, and service.
• Coach reviewers on consistent application of medical‑necessity criteria, medical policy, and benefit plan language; provide real‑time guidance and escalation support for questions or variation in interpretation.
• Monitor daily workflow health (intake volume, aging, and turnaround risks) and coordinate coverage plans; communicate barriers and risks to the UM Manager with recommendations.
• Reinforce documentation and communication standards by reviewing work for completeness and audit readiness; provide feedback to strengthen clarity of clinical rationale and regulatory timeliness.
• Support onboarding and skill development through shadowing plans, job aids, and competency check‑ins; elevate training needs and propose targeted learning solutions.
• Partner with providers, facilities, and internal teams (e.g., Case Management, Appeals, Provider Relations) to resolve barriers to timely determinations and ensure appropriate next steps.
• Maintain confidentiality and comply with HIPAA and company privacy/security policies; model professional conduct and ethical decision‑making.
• Complete required training and attestations within established timelines and reinforce team completion through reminders and follow‑through.

KEY COMPETENCIES (BY LEVEL)

• Clinical judgment and criteria‑based decision support: reinforces consistent application of medical policy, benefit language, and medical‑necessity criteria; recognizes when escalation is appropriate.
• Frontline leadership presence: models professionalism, supports team engagement, and provides clear direction and coaching aligned to standards.
• Communication and influence: communicates clearly with reviewers, providers/facilities, and internal partners; explains clinical rationale and next steps in a respectful, service‑oriented manner.
• Quality mindset: attention to documentation quality, timeliness requirements, and audit‑ready work; responds to feedback and incorporates learnings into daily practice.
• Remote leadership effectiveness: dependable attendance, organization, and ability to troubleshoot common technical issues; maintains visibility and responsiveness through collaboration tools.
• Technology and business acumen: proficient with UM platforms and standard office tools; understands medical terminology and basic coding concepts (ICD‑10, CPT, HCPCS) sufficient to support accurate UM documentation.
• Synthesizes complex operational/clinical issues into clear recommendations; escalates risks and proposes solutions.

Physical and Mental Requirements:

• Ability to perform the essential job functions safely and successfully with or without reasonable accommodation, including meeting established quality, timeliness, and compliance expectations.
• 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.

This job description is not an exclusive or exhaustive list of all job functions that an employee in this position may be asked to perform. Duties and responsibilities can be changed, expanded, reduced, or delegated by management to meet the business needs of Medcom.

Qualifications

What You Bring to Our Team

In order to represent the best of what we have to offer you come to us with a multitude of positive attributes including:

• Knowledge of medical claims and ICD‑10, CPT, HCPCS coding.
• Ability to critically evaluate claims data and determine treatment plan.
• Excellent interpersonal and communication skills; strong customer orientation; good time management skills; highly organized.
• 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.
• Ability to understand and interpret complex information from others.

You also take pride in offering the following Core Skills, Competencies, and Characteristics:

• RN Licensure required.
• Licensed in the state of California preferred.
• Prior supervisory experience in utilization review, case management, or an equivalent combination of education and experience.
• 5 + years combined clinical experience required.
• > 2 years utilization review experience required.

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!

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-$43 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.