Utilization Review Nurse-RN

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.

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Job Summary

The Utilization Review Nurse will provide professional assessments and review for the medical necessity of treatment requests and plans. The standard work schedule is Monday through Friday, 8:00 AM–5:00 PM Pacific Standard Time, with rotating weekend coverage as required.

What You'll Actually Do

• Provide professional assessment and review for the medical necessity of treatment requests and plans.
• Provide first level review for all outpatient and ancillary pre-certification requests for medical appropriateness; inpatient hospital stay including mental health, substance abuse, skilled nursing, and rehabilitation for medical necessity; and post claim or post service reviews. Staff are expected to cross train, and provide cross coverage as needed.
• Work to the top of the RN license and ensure proper referral to medical director for denial authorizations through independent review organizations (IRO).
• Work with hospital staff to prepare patients for discharge and ensure a smooth transition to the next level of care.
• Refer requests that fall outside of established guidelines to advance review or senior care consultants.
• Process appeals for non-certification of services, complete non-certification letters when appropriate.
• Review plan document for benefit determinations; attempt to redirect providers and patients to PPO providers.
• Identify and refer potential cases to case management, wellness, chronic disease and Nurturing Together programs.
• Complete documentation for all reviews in appropriate documentation software.
• Utilize guidelines in appropriate hierarchy. Guidelines include MCG guidelines, internal medical policies, group specific policies, and NCCN.
• Ability to meet productivity, quality, and turnaround times daily.
• Ability to pass external audits to include URAC and NCQA.
• Maintain HIPPA compliance per company’s policy and procedures.
• Maintain confidentiality and minimum requirement rules.
• Complete all required yearly training per company’s expected time limit.
• Complete and pass all annual testing including IRRA at 90% or higher.
• Ability to meet productivity, quality, and turnaround times daily.
• Ability to pass external audits to include URAC and NCQA.
• Maintain HIPPA compliance per company’s policy and procedures.
• Maintain confidentiality and minimum requirement rules.
• Complete all required yearly training per company’s expected period

What You Bring to Our Team

Education and Experience

• Current RN license in the United States or U.S. territory.
• Associate’s degree or diploma (Nursing program) required.
• 1+ year clinical experience required.
• Required Knowledge, Skills, and Abilities

Required Knowledge, Skills, and Abilities

• Ability to perform the essential job functions safely and successfully with or without reasonable accommodation, including meeting qualitative and/or quantitative productivity standards.
• 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.
• Occasional to frequent twisting of neck; occasional bending of neck and at waist.

  Work Environment

  At Personify Health we value and celebrate diversity, and we are committed to creating an inclusive environment for all employees. We believe in creating teams made up of individuals with various backgrounds, experiences, and perspectives. Why? Because diversity inspires innovation, collaboration, and challenges us to produce better solutions. But more than this, diversity is our strength, and a catalyst in our ability to change lives for the good. 

  Physical Requirements

  • Must be able to remain in a stationary position 50% of the time.
  • The person in this job needs to occasionally move about inside the office to access office machinery, filing cabinets and meeting facilities.
  • Constantly operates a computer and other office productivity machinery, such as copy machine, computer printer, calculator, etc.
  • Frequently positions self to maintain files in file cabinets.
  • Frequently moves boxes or equipment weighing up to 25 pounds.
  • Must communicate information and ideas so others understand. Must be able to exchange accurate information in these situations.
  • Must be able to observe details at close range.

   

  Disclaimer

  This job description is not intended to contain a comprehensive list of activities, duties, or responsibilities, but constitutes a general description of the scope and function of the role within the company. Activities, duties, and responsibilities are subject to change at any time with or without notice.

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? 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-$38 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 talent@personifyhealth.com. View all legitimate openings at personifyhealth.com/careers.