Clinical Guide Part A: (UM) Utilization Management Nurse

Location: Remote USA; full-time work across five 8-hour days, with most schedules including one weekend day and coverage aligned to Eastern Time.

Salary: $82,680–$96,460 per year.

Company

hirify.global provides an integrated care platform combining clinical and service experiences with data and AI to improve healthcare for older Americans.

What you will do

• Conduct prospective, concurrent, and retrospective utilization reviews for inpatient, behavioral health, and post-acute services.
• Evaluate medical necessity, level of care, treatment plans, timing, setting, and length of stay using clinical criteria and CMS guidelines.
• Perform admission, concurrent, discharge, and post-acute reviews for services including SNF, LTACH, ARU, and Home Health.
• Refer cases that do not meet criteria to the Medical Director, prepare clinical summaries, and coordinate peer-to-peer discussions.
• Monitor utilization to promote appropriate resource use while maintaining member-centered care.
• Document determinations accurately and maintain compliance with CMS, Medicare Advantage, and internal standards.

Requirements

• Unrestricted RN license and at least 4 years of clinical experience.
• At least 3 years of experience in utilization review, utilization management, case management, discharge planning, care coordination, or clinical appeals.
• Familiarity with CMS regulations and Medicare Advantage requirements or comparable payer coverage experience.
• Experience escalating cases for physician review and preparing clinical summaries.
• Ability to work one of the posted schedules, including a weekend day for most schedules; flexibility across multiple schedules is preferred.
• Ability to work effectively in a fast-paced, continuously changing environment.

Nice to have

• Experience with AI or LLM technologies.
• InterQual certification.

Culture & Benefits

• Employer-sponsored health, dental, and vision plans with low or no premium.
• Generous paid time off and parental leave.
• $100 monthly mobile or internet stipend.
• Stock options for all employees and bonus eligibility for most roles.
• 401(k) program and a supportive, collaborative work environment.