Utilization Review Nurse – RN

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

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.

Ready to turn clinical expertise into life-changing decisions, one review at a time?

Why This Role Matters

Every determination you make decides whether a member gets the care they need, when they need it. This role sits at the exact point where clinical judgment meets real-world impact, translating evidence-based criteria into decisions that protect members and keep the organization compliant, efficient, and trusted. Get it right, and members move forward with the right care in the right setting, network partners stay strong, and the organization avoids costly, avoidable risk. Get it wrong, or get it slow, and everyone feels it, from the member waiting on an answer to the Medical Director who depends on a clean, well-documented case. Your reviews are the front line of quality, and your accuracy is what turns a good UM program into a great one.

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

What You'll Actually Do

• Conduct medical-necessity reviews: Evaluate requested services against benefit language, medical policy, and nationally recognized criteria (MCG, NCCN) to determine the appropriate level of care, applying state and federal requirements at every step.
• Escalate non-certifications with precision: Route cases that don't meet criteria to the Medical Director for secondary clinical review, ensuring every adverse determination is timely, defensible, and aligned with NCQA/URAC accreditation standards.
• Dig into the clinical record: Analyze documentation for completeness, flag acuity and risk indicators, catch inconsistencies or gaps, and act fast with outreach or escalation when something doesn't add up.
• Prioritize with purpose: Manage a caseload by urgency, regulatory deadline, and member impact, and flag barriers early so determinations stay timely and compliant.
• Redirect care in-network: Confirm eligibility, benefits, authorization, and network status to steer members toward in-network, benefit-compliant options when clinically appropriate.
• Build the appeals case: Prepare clinical summaries and documentation, coordinate peer-to-peer discussions with physicians, and route appeals (including IRO referrals) accurately and on time.
• Document with rigor: Capture every review, rationale, criteria citation, and outcome in UM systems in real time, creating a clean audit trail that supports quality oversight and reporting.
• Hit the bar, every time: Meet productivity, quality, accuracy, and turnaround standards, participate in calibration activities, and put feedback into action immediately.
• Protect what matters: Maintain HIPAA compliance and confidentiality using minimum-necessary standards, and stay current on required training and annual competencies.
• Show up for the team: Cross-train and flex into coverage roles as needed, keeping operations running and service commitments met.

What You Bring to Our Team

Education & Experience:

• 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)

Technical Skills:

• Proficiency with Microsoft Word, Excel, and Outlook
• Working knowledge of ICD-10, CPT, and HCPCS coding and medical claims
• Ability to interpret medical records and apply evidence-based criteria and plan medical policies
• Comfort working across multiple screens and systems with strong typing proficiency
• Ability to work independently within UM platforms and workflows after training

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

Compensation: This position offers a base salary range of $30.00-$38.00 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.

Stay Safe:Personify Health will never ask for payment or sensitive personal information like social security numbers during hiring. All official communication comes from verified company email addresses and or our secure applicant tracking system. Suspicious requests? Report them to [e-mail] . View all legitimate openings at personifyhealth.com/careers .