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Utilization Review Nurse-RN

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Personify Health

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Location:
United States

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Category:
Nursing

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Contract Type:
Not provided

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Salary:

30.00 - 38.00 USD / Hour
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Job Description:

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 Time, with rotating weekend coverage required.

Job Responsibility:

  • 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
  • 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

Requirements:

  • Current RN license in the United States or U.S. territory
  • Associate’s degree or diploma (Nursing program) required
  • 1+ year clinical experience required
  • 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
  • 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
What we offer:
  • Competitive base salary and benefits effective day one
  • Comprehensive medical and dental through our own health solutions
  • Paid Time Off
  • Mental health support, retirement planning, and financial protection
  • Professional development with clear career progression and learning budgets

Additional Information:

Job Posted:
March 21, 2026

Employment Type:
Fulltime
Work Type:
Remote work
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