RN Utilization Review: Drive Accurate Care Decisions

Personify Health; Northern (KY); Hybrid; USD 41,000 - 52,000; Full time

Benefits offered by this job

Medical & dental

Paid time off

Mental health support

Retirement plan

Professional development

Career progression

Job summary

Personify Health is seeking a qualified RN to perform medical-necessity reviews, ensuring appropriate care levels and strict adherence to policy language and regulatory requirements.

You will evaluate documentation, escalate non-certifications, and coordinate with Medical Directors to maintain timely, compliant determinations across in-network options. Strong clinical judgment and HIPAA discipline are essential.

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)

Responsibilities

• Conduct medical-necessity reviews: Evaluate requested services against benefit language, medical policy, and nationally recognized criteria to determine level of care.
• Escalate non-certifications with precision: Route cases to Medical Director for secondary review, ensuring timely, defensible determinations.
• Dig into the clinical record: Analyze documentation for completeness and risk indicators, flag gaps, and escalate when needed.
• Prioritize with purpose: Manage caseload by urgency, deadlines, and member impact.
• Redirect care in-network: Confirm eligibility, benefits, authorization, and network status for in-network options.
• Build the appeals case: Prepare clinical summaries, coordinate peer-to-peer discussions, route appeals.
• Document with rigor: Record review rationale and outcomes in UM systems for audit trails.
• Hit the bar: Meet productivity, quality, and turnaround standards; participate in calibration.
• Protect confidentiality: Maintain HIPAA compliance and required training.
• Show up for the team: Cross-train and cover roles as needed.

Skills

RN license

ADN or diploma

1-2+ years clinical experience

MS Word Excel Outlook

ICD-10 CPT HCPCS

Medical records interpretation

HIPAA knowledge

Independent work

Education

ADN or diploma

BSN preferred

Accredited nursing program

Tools

UM systems

Job description

Personify Health is seeking a qualified RN to perform medical-necessity reviews, ensuring appropriate care levels and strict adherence to policy language and regulatory requirements.

You will evaluate documentation, escalate non-certifications, and coordinate with Medical Directors to maintain timely, compliant determinations across in-network options. Strong clinical judgment and HIPAA discipline are essential.