Job Description

Overview:

Who We Are

Ready to create a healthier world? We are ready for you! Personify Health is on a mission to simplify and personalize the health experience to improve health and reduce costs for companies and their people. At Personify Health, we believe in offering total rewards, flexible opportunities, and a diverse inclusive community, where every voice matters. Together, we’re shaping a healthier, more engaged future.

Ready to Make Critical Decisions That Ensure Appropriate Patient Care?

We're seeking a full time skilled RN who understands that utilization review is about ensuring patients receive the right care at the right time. As our Utilization Review Nurse, you'll use clinical expertise to assess medical necessity, support appropriate care transitions, and serve as an advocate for both quality care and cost-effective treatment options while working collaboratively with medical directors and care teams.

What makes this role different

✓ Clinical decision-making: Your assessments directly impact patient care and treatment authorization decisions across multiple service lines

✓ Comprehensive scope: Review outpatient/ancillary pre-certifications, inpatient stays including mental health and substance abuse, skilled nursing, rehabilitation, and post-service reviews

✓ Care coordination focus: Work with hospital staff to ensure smooth patient transitions and optimal discharge planning to appropriate next-level care

✓ Professional autonomy: Make independent clinical judgments using MCG guidelines, internal medical policies, and NCCN while collaborating with medical directors

What You'll Actually Do

Assess medical necessity: Conduct professional reviews of treatment requests and plans for medical appropriateness using established clinical guidelines and evidence-based criteria.

Coordinate care transitions: Partner with hospital staff to prepare patients for discharge while ensuring smooth transitions to appropriate next-level care arrangements.

Navigate complex cases: Review outpatient pre-certifications, inpatient hospital stays including mental health and substance abuse treatments, skilled nursing, and rehabilitation requirements with clinical expertise.

Ensure appropriate referrals: Work to top of RN license while ensuring proper referral to medical director for denial authorizations through independent review organizations (IRO).

Support member wellness: Identify and refer appropriate cases to case management, wellness, chronic disease, and Nurturing Together programs while maintaining thorough documentation.

Process appeals: Handle appeals for non-certification of services and complete non-certification letters when appropriate while reviewing plan documents for benefit determinations.

Maintain compliance excellence: Meet productivity, quality, and turnaround time requirements while maintaining HIPAA compliance and passing external URAC and NCQA audits.

Utilize clinical guidelines: Apply guidelines in appropriate hierarchy including MCG guidelines, internal medical policies, group-specific policies, and NCCN for consistent decision-making.

What You Bring to Our Mission

The clinical foundation:

• Current RN license in United States or U.S. territory
• Associate's degree or diploma (Nursing program) required
• 1+ year clinical experience required

The professional competencies:

• Ability to meet productivity, quality, and turnaround time requirements daily
• Capability to pass external audits including URAC and NCQA
• Commitment to maintaining HIPAA compliance per company policies and procedures
• Ability to complete and pass all annual testing including IRRA at 90% or higher
• Willingness to cross-train and provide cross-coverage as needed

The clinical expertise:

• Strong clinical judgment for assessing medical necessity across multiple service lines
• Knowledge of MCG guidelines, internal medical policies, and clinical decision-making tools
• Ability to review plan documents and attempt to redirect providers and patients to PPO providers when beneficial
• Proficiency with documentation software and electronic health systems

The professional qualities:

• Excellent communication skills with ability to explain complex medical information clearly
• Independent judgment combined with collaborative team approach
• Commitment to maintaining confidentiality and minimum requirement rules
• Ability to complete all required yearly training per company's expected time period
• Comfort navigating fast-paced, high-volume review environment while maintaining quality standards

Why You'll Love It Here

We believe in total rewards that actually matter—not just competitive packages, but benefits that support how you want to live and work.

Your wellbeing comes first:

• Comprehensive medical and dental coverage through our own health solutions (yes, we use what we build!)
• Mental health support and wellness programs designed by experts who get it
• Flexible work arrangements that fit your life, not the other way around

Financial security that makes sense:

• Retirement planning support to help you build real wealth for the future
• Basic Life and AD&D Insurance plus Short-Term and Long-Term Disability protection
• Employee savings programs and voluntary benefits like Critical Illness and Hospital Indemnity coverage

Growth without limits:

• Professional development opportunities and clear career progression paths
• Mentorship from industry leaders who want to see you succeed
• Learning budget to invest in skills that matter to your future

A culture that energizes:

• People Matter: Inclusive community where every voice matters and diverse perspectives drive innovation
• One Team One Dream: Collaborative environment where we celebrate wins together and support each other through challenges
• We Deliver: Mission-driven work that creates real impact on people's health and wellbeing, with clear accountability for results
• Grow Forward: Continuous learning mindset with team events, recognition programs, and celebrations that make work genuinely enjoyable

The practical stuff:

• Competitive base salary that rewards your success
• PTO policy because rest and recharge time is non-negotiable
• Benefits effective day one—because you shouldn’t have to wait to be taken care of

Ready to create a healthier world while building the career you want? We're ready for you.

No candidate will meet every single qualification listed. If your experience looks different but you think you can bring value to this role, we'd love to learn more about you.

Personify Health is an equal opportunity organization and is committed to diversity, inclusion, equity, and social justice.

In compliance with all states and cities that require transparency of pay, the base compensation for this position ranges from $30 to $38 per hour. Note that compensation may vary based on location, skills, and experience. This position is eligible for benefits.

We strive to cultivate a work environment where differences are celebrated, and employees of all backgrounds are empowered to thrive. Personify Health is committed to driving Diversity, Equity, Inclusion and Belonging (DEIB) for all stakeholders: employees (at each organization level), members, clients and the communities in which we operate. Diversity is core to who we are and critical to our work in health and wellbeing.

#WeAreHiring #PersonifyHealth

Beware of Hiring Scams: Personify Health will never ask for payment or sensitive personal information such as social security numbers during the hiring process. All official communication will come from a verified company email address. If you receive suspicious requests or communications, please report them to talent@personifyhealth.com. All of our legitimate openings can be found on the Personify Health Career Site.

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