Utilization Review Nurse – RN

Personify Health

. Evaluate requested services against benefit language, medical policy, and nationally recognized criteria such as MCG and NCCN .

Posted 9/16/2026full-timeRemote • United StatesJunior💰 $30 - $40 per hourWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in clinical evaluation and utilization management, ensuring compliance with NCQA/URAC standards while effectively managing caseloads and documentation. Proficient in interpreting medical records and applying evidence-based criteria within healthcare systems.

Highest-signal resume keywords

Current RN LicenseUtilization Review ExperienceICD-10, CPT, HCPCS Coding KnowledgeClinical Documentation AnalysisHIPAA Compliance

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical EvaluationUtilization ManagementMedical Policy InterpretationDocumentation PreparationCase RoutingRisk Indicator AnalysisTyping ProficiencyClinical Summary PreparationEligibility ConfirmationPeer-to-Peer Coordination

Soft Skills

Independent WorkAttention to DetailEffective CommunicationTime ManagementProblem Solving

Tools & Technologies

UM SystemsMicrosoft WordMicrosoft ExcelMicrosoft Outlook

Certifications & Qualifications

RN LicenseADN or Diploma in Nursing

Industry Keywords

NCQA StandardsURAC AccreditationAcute CareMed-SurgICUEDMedical ClaimsEvidence-Based CriteriaRegulatory ComplianceClinical Documentation

About the role

Key responsibilities & impact

Evaluate requested services against benefit language, medical policy, and nationally recognized criteria such as MCG and NCCN
Determine the appropriate level of care while applying state and federal requirements
Route cases that do not meet criteria to the Medical Director for secondary clinical review
Ensure adverse determinations are timely, defensible, and aligned with NCQA/URAC accreditation standards
Analyze clinical documentation for completeness and identify acuity, risk indicators, inconsistencies, and gaps
Conduct outreach or escalation when documentation issues are identified
Manage caseloads according to urgency, regulatory deadlines, and member impact
Confirm eligibility, benefits, authorization, and network status
Steer members toward in-network, benefit-compliant options when clinically appropriate
Prepare clinical summaries and documentation for appeals
Coordinate peer-to-peer discussions with physicians and route appeals, including IRO referrals
Document reviews, rationales, criteria citations, and outcomes in UM systems in real time
Meet productivity, quality, accuracy, and turnaround standards
Participate in calibration activities and apply feedback
Maintain HIPAA compliance and complete required training and annual competencies
Cross-train and provide coverage support as needed

Requirements

What you’ll need

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 in acute care, med-surg, ICU/ED, or similar setting
Utilization review/utilization management experience preferred
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
Ability to work Monday–Friday, 8:00 AM–5:00 PM Pacific Time, with rotating Saturday coverage as required
HIPAA compliance and confidentiality using minimum-necessary standards

Benefits

Comp & perks

Competitive base salary
Comprehensive medical and dental through our own health solutions
Paid Time Off
Mental health support
Retirement planning
Financial protection
Professional development with clear career progression and learning budgets
Mission-driven culture where diverse perspectives drive real impact
Wellness programs
Other employee perks
Full benefits package effective day one