Clinical Guide: (UM) Utilization Management Nurse (Outpatient Prior Authorization)

Location: Remote USA; Monday–Friday or Sunday–Thursday schedules, working 8-hour shifts between 10:00 AM and 8:00 PM ET.

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 timely clinical reviews of outpatient authorization requests using evidence-based medical necessity criteria, CMS requirements, Medicare Advantage rules, and health plan policies.
• Evaluate requests for outpatient procedures, imaging, therapy, durable medical equipment, and home health services.
• Determine appropriate services and settings of care, recommending clinically appropriate alternatives when relevant.
• Escalate cases that do not meet criteria to the Medical Director, preparing clinical summaries and supporting peer-to-peer discussions.
• Communicate with providers and internal teams to obtain documentation, resolve questions, and explain clinical and coverage information.
• Meet CMS turnaround standards while maintaining accurate documentation and identifying quality assurance or risk management issues.

Requirements

• Unrestricted RN license and at least 4 years of RN experience.
• At least 3 years of utilization management, utilization review, or prior authorization experience in a health plan, hospital, or post-acute setting.
• Knowledge of CMS guidelines and Medicare Advantage requirements.
• Experience escalating cases and preparing clinical summaries for physician review.
• Ability to work at pace, meet daily turnaround standards, adapt to changing policies and workflows, and multitask while listening, speaking, and typing.

Nice to have

• Outpatient prior authorization experience, particularly with home health and durable medical equipment.
• Proficiency with Google Workspace and AI tools.
• Ability to simplify complex information and adapt communication to different audiences.
• Transparency, service orientation, and interest in improving the healthcare experience.

Culture & Benefits

• Remote full-time work with multiple schedule options and consideration of schedule preferences.
• 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 and bonus eligibility for eligible full-time roles.
• 401(k) program and a supportive, collaborative, and inclusive work environment.