Part-Time Utilization Review Nurse - RN

Position Overview

Now is the time to join us! We’re Personify Health – the first and only personalized health platform company to bring health, wellbeing, and navigation solutions together. We help businesses optimize investments in their members while empowering people to meaningfully engage with their health. At Personify Health, we offer total rewards, flexible opportunities, and a diverse, inclusive community where every voice matters. Together, we’re shaping a healthier, more engaged future.

Key Responsibilities

• Under the supervision of an RN, provide professional assessment and review for the medical necessity of treatment requests and plans.
• Conduct first level reviews for outpatient and ancillary pre-certification requests, and inpatient hospital stays (including mental health, substance abuse, skilled nursing, and rehabilitation) for medical necessity.
• Ensure proper referral to the medical director for denial authorizations via independent review organizations (IRO).
• Collaborate with hospital staff to prepare patients for discharge and ensure a smooth transition of care.
• Refer requests outside established guidelines to advance review or senior care consultants and process appeals for non-certification of services.
• Review plan documents for benefit determinations and attempt to redirect providers and patients to PPO providers.
• Identify and refer potential cases to case management, wellness, chronic disease initiatives, and the Nurturing Together program.
• Complete all documentation in Eldorado/Episodes while maintaining confidentiality, utilizing MCG guidelines, medical policies, Medscape, and NCCN resources.
• Meet daily productivity, quality, and turnaround time targets.

Required Qualifications

• Current RN license in the United States or U.S. territory.
• 1+ years of clinical experience.

Preferred Qualifications

• Knowledge of medical claims and ICD-10, CPT, HCPCS coding.
• Proficiency in software applications including Microsoft Word, Excel, PowerPoint, and Outlook.
• Excellent verbal and written communication skills with the ability to convey complex information clearly.

Benefits & Perks

• Competitive Compensation: $25.00 to $28.00 per hour (compensation may vary based on location, skills, and experience).
• Flexible part-time opportunity (up to 20 hours per week with weekend availability) to support work-life balance.
• Total rewards package with professional development opportunities.
• A diverse, inclusive work environment committed to Diversity, Equity, Inclusion, and Belonging.