Personify Health

Nurse

• 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

Utilization Review Nurse – RN