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Utilization Review Nurse I LVN/LPN

$25 - $30 / hour

Overview: 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. Responsibilities: Ready to make sure every member gets the right care at the right time? Why This Role Matters Behind every prior authorization and inpatient stay is a member waiting on a decision, and you’re the one who makes sure that decision is timely, accurate, and grounded in evidence. As a Level I Utilization Management Nurse, you review requests for medical necessity, level of care, and benefit coverage, then apply clinical guidelines and plan policies to keep care appropriate and compliant. Your sharp review work protects members from delays and unnecessary services, supports providers who need clear answers, and keeps our programs ready for URAC and NCQA scrutiny. When your reviews are thorough, well-documented, and delivered on time, our whole organization earns the trust of the members and sponsors who rely on us. Schedule: Monday–Friday, 8:00 AM–5:00 PM Pacific Time, with rotating Saturday coverage as required. What You’ll Actually Do Perform clinical reviews that drive sound determinations: Evaluate requests for medical necessity, appropriate level of care, documentation completeness, and benefit coverage, so members get timely decisions that meet compliance standards. Deliver first-level review across care settings: Review outpatient and ancillary pre-certification and prior authorization requests, inpatient stays (including behavioral health, substance use, skilled nursing, and rehabilitation), and post-service or post-claim reviews as assigned. Apply guidelines in the right hierarchy: Use internal medical policies, group-specific policies, NCCN, and MCG as applicable, and record your criteria and policy rationale in the UM system so every decision stands on solid ground. Escalate the cases that need advanced eyes: Refer requests that fall outside guidelines, fail to meet criteria, or may require adverse determination to senior staff or the Medical Director, and support IRO referrals in line with policy and jurisdictional requirements. Verify benefits and guide members in-network: Review plan documents to support benefit determinations, and redirect providers and members to PPO or in-network options when it fits plan requirements. Build audit-ready case summaries: Prepare clear, complete documentation for Medical Director review, including adverse determination and IRO referral pathways, so every case holds up under scrutiny. Hit productivity, quality, and turnaround targets: Meet established standards, take part in quality activities like inter-rater reliability (IRRA), and apply feedback to keep us audit-ready for URAC, NCQA, and other applicable standards. Protect member privacy at every step: Follow HIPAA and minimum-necessary standards, and complete required annual training and testing on time. Cross-train and cover where the team needs you: Step in to support team operations and service-level commitments, and contribute to staff training as appropriate. Qualifications: What You Bring to Our Team Education & Experience: Graduate of an accredited nursing program (LVN/LPN) Current, unrestricted U.S. or U.S. territory nursing license (compact license acceptable where applicable) Minimum 1-2 years of recent clinical experience in acute care, med-surg, ICU/ED, or another relevant setting Prior utilization review or utilization management experience preferred Technical Skills: Ability to interpret medical records and apply evidence-based criteria and plan medical policies Working knowledge of clinical guidelines such as MCG and NCCN, and UM documentation systems Proficiency with Microsoft Word, Excel, Outlook, and Teams, with the ability to learn additional tools as assigned Comfort working across multiple screens and a headset-based phone system, with proficient typing and accurate data entry Ability to use remote-work technology (e.g., VPN) and departmental platforms (e.g., SharePoint/Drives) in line with security policies 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 $25-$30 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 .

Telehealth

Full-time

1 week ago

Case Manager Nurse RN

Personify Health Remote, OR

$34 - $36 / hour

Overview: 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. Responsibilities: Ready to be the difference between a confusing diagnosis and a clear path forward? Why This Role Matters When someone gets a diagnosis that turns their world upside down, they need more than a claim number — they need a person who can guide them through it. As a Case Manager RN, you're that person: the clinical expert who assesses the whole picture, builds a real treatment plan, and stays connected with patients, providers, and families through every step of care. Your work directly shapes whether a member gets the right care at the right time, and whether costs stay manageable for the plans and employers who depend on us. This isn't administrative case tracking — it's clinical judgment applied to real people navigating some of the hardest moments of their lives. The outcomes you drive, case by case, are what make cost-effective, high-quality healthcare possible at scale. What You'll Actually Do Assess the whole patient: Contact patients directly and complete thorough assessments covering physical, psychosocial, emotional, spiritual, environmental, and financial needs to build a full clinical picture. Mine claims data for insight: Use claims processing tools to review paid claim data, identifying members who need case management or would benefit from specific programs. Build individualized treatment plans: Develop treatment plans for standard and catastrophic cases in collaboration with patients, caregivers, community resources, and multi-disciplinary providers, setting clear short- and long-term goals. Track outcomes and adjust course: Monitor interventions, evaluate treatment plan effectiveness in real time, and report measurable outcomes that show what's actually working. Stay connected across the care team: Maintain ongoing contact with patients, families, providers, employers, and the broader care team throughout the full continuum of care. Advocate for the patient: Facilitate access to quality care, help reduce overall costs, and provide direct emotional support and guidance to patients and families navigating difficult diagnoses. Drive cost management strategies: Negotiate and implement cost management approaches that improve outcomes, then reflect that impact in monthly case management reviews and cost avoidance reports. Perform utilization review: Conduct utilization review for assigned members to ensure care aligns with clinical need and plan guidelines. Connect members to wellness resources: Evaluate patient needs and make referrals into wellness programs when appropriate. Maintain airtight documentation: Keep complete, confidential documentation in Eldorado and UM Web, preparing reports at 30-day intervals for high-risk cases and 90-day intervals for low-risk cases, per Company policy and HIPAA. Mentor LVN colleagues: Serve as a clinical resource for LVNs, guiding them through complex cases and clinical decision-making. Qualifications: What You Bring to Our Team Education & Experience: Graduate of an accredited Registered Nursing (RN) program Current California RN license required; multi-state license also required Minimum of 5 years medical/surgical or acute care experience, including 2 years in case management, or an equivalent combination of education and experience Prior case management, emergency room, critical care, or other relevant clinical experience pertinent to case management Technical Skills: Knowledge of medical claims processing and ICD-10, CPT, and HCPCS coding Ability to critically evaluate claims data to inform treatment and discharge planning Knowledge of community resources and alternate funding programs Proficiency with Microsoft Office Suite Working knowledge of case management platforms such as Eldorado and UM Web 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 $34.00-$36.00 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 talent@personifyhealth.com . View all legitimate openings at personifyhealth.com/careers .

Utilization Review Nurse-LVN/LPN

Personify Health Remote, OR

$25 - $30 / hour

Overview: 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. Responsibilities: Utilization Review Nurse (LVN) The Utilization Review Nurse conducts first-level clinical reviews to determine the medical necessity and appropriateness of treatment requests, working under the supervision of a Registered Nurse. This role supports timely, accurate benefit determinations across outpatient, inpatient, and post-service claims while ensuring compliance with clinical guidelines and regulatory standards. Schedule: Monday–Friday, 8:00 AM–5:00 PM Pacific Time, with rotating Saturday coverage as required. What You'll Actually Do Provide first level review for all outpatient and ancillary pre-certification requests for medical appropriateness; all inpatient hospital stays including mental health, substance abuse, skilled nursing and rehabilitation for medical necessity; and all post claim or post service reviews. 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 program. Complete documentation for all reviews in Eldorado/Episodes; maintain confidentiality. Utilize MCG guidelines, medical policies, Medscape, and NCCN. Ability to meet productivity, quality, and turnaround times daily. Assists with department operations and implementations Qualifications: What You Bring to Our Team Education and Experience: Current LVN license in the United States or U.S. territory. 1+ years of clinical experience required. Required Knowledge, Skills, and Abilities: Knowledge of medical claims and ICD-10, CPT, HCPCS coding. Proficiency in software applications including, but not limited to, Microsoft Word, Microsoft Excel, Microsoft PowerPoint and Outlook Excellent verbal and written communication skills Ability to speak clearly and convey complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others 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 $25-$30 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 .

Telehealth

Full-time

1 month ago

Case Manager Nurse RN

Personify Health Remote, OR

$35 - $40 / hour

Overview: 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. Responsibilities: Ready to be the difference between a confusing diagnosis and a clear path forward? Why This Role Matters When someone gets a diagnosis that turns their world upside down, they need more than a claim number — they need a person who can guide them through it. As a Case Manager RN, you're that person: the clinical expert who assesses the whole picture, builds a real treatment plan, and stays connected with patients, providers, and families through every step of care. Your work directly shapes whether a member gets the right care at the right time, and whether costs stay manageable for the plans and employers who depend on us. This isn't administrative case tracking — it's clinical judgment applied to real people navigating some of the hardest moments of their lives. The outcomes you drive, case by case, are what make cost-effective, high-quality healthcare possible at scale. What You'll Actually Do Assess the whole patient: Contact patients directly and complete thorough assessments covering physical, psychosocial, emotional, spiritual, environmental, and financial needs to build a full clinical picture. Mine claims data for insight: Use claims processing tools to review paid claim data, identifying members who need case management or would benefit from specific programs. Build individualized treatment plans: Develop treatment plans for standard and catastrophic cases in collaboration with patients, caregivers, community resources, and multi-disciplinary providers, setting clear short- and long-term goals. Track outcomes and adjust course: Monitor interventions, evaluate treatment plan effectiveness in real time, and report measurable outcomes that show what's actually working. Stay connected across the care team: Maintain ongoing contact with patients, families, providers, employers, and the broader care team throughout the full continuum of care. Advocate for the patient: Facilitate access to quality care, help reduce overall costs, and provide direct emotional support and guidance to patients and families navigating difficult diagnoses. Drive cost management strategies: Negotiate and implement cost management approaches that improve outcomes, then reflect that impact in monthly case management reviews and cost avoidance reports. Perform utilization review: Conduct utilization review for assigned members to ensure care aligns with clinical need and plan guidelines. Connect members to wellness resources: Evaluate patient needs and make referrals into wellness programs when appropriate. Maintain airtight documentation: Keep complete, confidential documentation in Eldorado and UM Web, preparing reports at 30-day intervals for high-risk cases and 90-day intervals for low-risk cases, per Company policy and HIPAA. Mentor LVN colleagues: Serve as a clinical resource for LVNs, guiding them through complex cases and clinical decision-making. Qualifications: What You Bring to Our Team Education & Experience: Graduate of an accredited Registered Nursing (RN) program Current California RN license required; multi-state license also required Minimum of 5 years medical/surgical or acute care experience, including 2 years in case management, or an equivalent combination of education and experience Prior case management, emergency room, critical care, or other relevant clinical experience pertinent to case management Technical Skills: Knowledge of medical claims processing and ICD-10, CPT, and HCPCS coding Ability to critically evaluate claims data to inform treatment and discharge planning Knowledge of community resources and alternate funding programs Proficiency with Microsoft Office Suite Working knowledge of case management platforms such as Eldorado and UM Web 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 $35.00-$40.00 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 talent@personifyhealth.com . View all legitimate openings at personifyhealth.com/careers .

Utilization Review Nurse - RN

Personify Health Remote, OR

$30 - $40 / hour

Overview: 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. Responsibilities: 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. Qualifications: 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) Utilization review/utilization management experience preferred 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 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 $30.00-$40.00 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 talent@personifyhealth.com . View all legitimate openings at personifyhealth.com/careers .

Lead Utilization Review - RN

Personify Health Remote, OR

$38 - $44 / hour

Overview: 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. Responsibilities: Ready to lead the clinical team that keeps care moving when it matters most? Why This Role Matters Every delayed or unclear coverage decision is a person waiting on care they need. The RN UM Team Lead makes sure that doesn't happen — coaching reviewers to apply medical-necessity criteria consistently, catching risk before it becomes a backlog, and keeping documentation audit-ready so decisions hold up under scrutiny. This isn't a background role: it's the difference between a member getting a timely answer and getting stuck in a queue. You're the person providers and internal teams turn to when a case gets complicated and needs a clear path forward. When your team runs tight, members get faster answers, providers get fewer headaches, and the business stays compliant — that's the job. Schedule: Monday–Friday, 8:00 AM–5:00 PM Pacific Time, with rotating Saturday coverage as required. What You'll Actually Do Set daily direction for your UM team: Establish priorities, reinforce expectations, and build a culture where clinical quality and accountability are the norm, not the exception. Coach reviewers on criteria application: Guide consistent use of medical-necessity criteria, medical policy, and benefit language, and step in with real-time answers when interpretations vary. Monitor workflow health daily: Track intake volume, aging cases, and turnaround risk; flag barriers to the UM Manager with a recommendation attached, not just a problem. Audit for documentation quality: Review reviewer work for completeness and audit readiness, then coach for sharper clinical rationale and tighter regulatory timeliness. Build reviewer capability: Run shadowing plans, job aids, and competency check-ins for new and existing staff; identify training gaps and propose solutions before they become bigger problems. Resolve cross-team barriers: Partner with providers, facilities, Case Management, Appeals, and Provider Relations to clear roadblocks and keep determinations moving. Protect member and company data: Maintain HIPAA compliance and company privacy standards, and model the ethical decision-making you expect from your team. Drive training completion: Complete required training and attestations on time, and keep your team on track to do the same. Qualifications: What You Bring to Our Team What You Bring to Our Team Education & Experience: Active RN license Experience in utilization management, clinical review, or case management Background applying medical-necessity criteria and benefit plan interpretation in a healthcare payer or clinical review setting Technical Skills: Proficiency with UM platforms and standard office/productivity tools Working knowledge of medical terminology and coding concepts (ICD-10, CPT, HCPCS) sufficient to support accurate UM documentation Familiarity with remote collaboration tools for team visibility and responsiveness 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 $38.00-$44.00 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 talent@personifyhealth.com . View all legitimate openings at personifyhealth.com/careers .

Utilization Review

Telehealth

2 months ago

Utilization Review Nurse RN Part-Time

Personify Health Remote, OR

$30 - $38 / hour

Overview: 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. Responsibilities: We are seeking a Utilization Review Nurse to join our dynamic team on a part-time basis working up to 28 hours per week and weekends required. What You'll Actually Do Perform utilization management (UM) medical-necessity reviews and level-of-care determinations for requested services using the organization’s hierarchy of guidance (benefit language/plan documents, medical policies, nationally recognized evidence-based criteria such as MCG; NCCN as applicable) and applicable state/federal requirements. Apply criteria and policy consistently; when a request does not meet criteria, route timely to the Medical Director for secondary clinical review and potential adverse determination in accordance with UM policies and accreditation standards (e.g., NCQA/URAC, as applicable). Use critical thinking to analyze clinical documentation for completeness, identify key risk/acuity indicators, recognize inconsistencies or missing information, and initiate timely outreach/escalation per UM workflow. Apply strategic thinking within established guidelines by prioritizing workload based on urgency, regulatory/accreditation time frames, and potential member impact; communicate barriers early to support timely, compliant determinations. Assist with in-network and benefit-compliant redirection when clinically appropriate by confirming eligibility, benefits, authorization requirements, and network status. Support the appeals process by preparing clinical summaries and documentation; coordinating peer-to-peer/MD discussions when indicated; and ensuring timely routing/escalation per policy (including Independent Review Organization (IRO) processes when required). Document reviews, rationale, criteria/policy citations, communications, and outcomes accurately and contemporaneously in designated UM systems to support quality oversight, reporting, and audit readiness. Meet established productivity, quality, accuracy, and turnaround-time standards; participate in calibration/quality activities; and incorporate feedback into daily practice. Maintain HIPAA compliance and confidentiality using minimum-necessary standards; complete required training and annual competencies within established deadlines. Cross-train and provide cross-coverage as needed to support team operations and service-level commitments. Qualifications: What You Bring to Our Team Current, unrestricted RN license in the United States or U.S. territory (compact license acceptable where applicable). Graduate of an accredited nursing program (ADN or diploma required; BSN preferred). Minimum 1-2 years of recent clinical experience (e.g., acute care, med-surg, ICU/ED, or other relevant setting). Prior utilization review/utilization management experience preferred. Ability to interpret medical records and apply evidence-based criteria and plan medical policies with appropriate escalation to Medical Director for non-certifications. UPON HIRE, must have: Basic computer literacy The ability to work on multiple screens, and proficient typing skills. Proficiency in software applications including, but not limited to, Microsoft Word, Microsoft Excel, and Outlook Excellent verbal and written communication skills Ability to speak clearly and convey complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others. Ability to work independently and utilize written resources to problem solve. Ability to work independently within appropriate programs after training. Knowledge of medical claims and ICD-10, CPT, HCPCS coding Excellent verbal and written communication skills for upward and downward conversations Physical and Mental Requirements: 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. This job description is not an exclusive or exhaustive list of all job functions that an employee in this position may be asked to perform. Duties and responsibilities can be changed, expanded, reduced, or delegated by management to meet the business needs of MedCom. 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 talent@personifyhealth.com . View all legitimate openings at personifyhealth.com/careers .

Utilization Review Nurse - LVN / LPN

Personify Health Remote, OR

$25 - $31 / hour

Overview: 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. Responsibilities: Ready to be the clinical judgment call that keeps care on track? Why This Role Matters Every pre-certification, every inpatient stay, every appeal that lands on your desk is a moment where your review decides what happens next for a real person's care. This role is where clinical assessment meets real consequence, making sure treatment requests get matched to the right level of care, the right setting, and the right guidelines every single time. Get it right, and patients move through the system smoothly, providers stay aligned with plan benefits, and the organization avoids unnecessary cost and risk. Get it wrong, or get it slow, and care gets delayed or denied when it shouldn't be. Your accuracy and pace are what keep the entire utilization review process trustworthy. Schedule: Monday–Friday, 8:00 AM–5:00 PM Pacific Time, with rotating Saturday coverage as required. What You'll Actually Do Own first-level reviews: Assess outpatient, ancillary, and inpatient pre-certification requests, including mental health, substance abuse, skilled nursing, and rehab stays, for medical appropriateness and necessity. Drive post-service reviews: Evaluate post-claim and post-service requests against clinical guidelines to confirm medical necessity after the fact. Escalate the right cases: Route denial authorizations to the Medical Director and, when required, through Independent Review Organizations (IRO), and refer out-of-guideline requests to advance review or senior care consultants. Coordinate smooth discharges: Work directly with hospital staff to prepare patients for discharge and set up a clean transition to the next level of care. Manage the appeals process: Process appeals for non-certified services and complete non-certification letters accurately and on time. Redirect care in-network: Review plan documents for benefit determinations and steer providers and patients toward PPO options whenever possible. Connect patients to the right program: Identify and refer cases to case management, wellness, chronic disease, and Nurturing Together programs when clinical needs point that way. Document every review: Complete accurate, timely documentation in Eldorado/Episodes for every case, maintaining strict confidentiality throughout. Apply the right criteria: Use MCG guidelines, medical policies, Medscape, and NCCN to ground every determination in evidence-based standards. Hit the bar, every time: Meet daily productivity, quality, and turnaround-time standards, and support department operations and new initiatives as they roll out. Qualifications: What You Bring to Our Team Education & Experience: Current LVN license in the United States or a U.S. territory 1+ years of clinical experience Technical Skills: Working knowledge of medical claims and ICD-10, CPT, and HCPCS coding Proficiency with Microsoft Word, Excel, PowerPoint, and Outlook Familiarity with MCG guidelines, NCCN criteria, and Medscape Experience documenting reviews in utilization management systems (e.g., Eldorado/Episodes) 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 $25.00-$31.00 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 talent@personifyhealth.com . View all legitimate openings at personifyhealth.com/careers .

Utilization Review Nurse - RN

Personify Health Remote, OR

$35 - $43 / hour

Overview: 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. Responsibilities: 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. Qualifications: 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) Utilization review/utilization management experience preferred 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 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 $35.00-$43.00 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 talent@personifyhealth.com . View all legitimate openings at personifyhealth.com/careers .