Utilization Review RN — Impactful Care Decisions

Personify Health; United States; On-site; USD 62,000 - 83,000; Full time

Benefits offered by this job

Competitive base salary

Benefits from day one

PTO and wellbeing programs

Mental health support

Career development

Job summary

Personify Health is seeking a registered nurse to perform utilization review and case determinations. You will evaluate medical necessity, ensure policy alignment, and maintain a detailed audit trail across UM systems.

Ideal candidates have 1–2+ years of clinical experience and utilization review exposure. The role includes Pacific Time scheduling, strong documentation, and collaboration with medical leadership. Competitive benefits apply from day one.

Qualifications

• Current, unrestricted RN license in the United States
• 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)
• Utilization review/utilization management experience preferred

Responsibilities

• 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.

Skills

Clinical judgment

Attention to detail

Documentation accuracy

Independent work

Education

RN license (US)

ACN/ diploma or ADN

BSN preferred

Tools

Microsoft Word

Excel

Outlook

ICD-10 coding

CPT coding

HCPCS coding

Job description

Personify Health is seeking a registered nurse to perform utilization review and case determinations. You will evaluate medical necessity, ensure policy alignment, and maintain a detailed audit trail across UM systems.

Ideal candidates have 1–2+ years of clinical experience and utilization review exposure. The role includes Pacific Time scheduling, strong documentation, and collaboration with medical leadership. Competitive benefits apply from day one.