Senior Virtual Utilization Review Specialist - Denials (Healthcare)

Location: Remote nationwide within the United States; candidates must reside in and be authorized to work in the United States and must be able to travel to client, temporary, or corporate offices when required.

Salary: $32.65–$43.90 per hour, based on experience.

Company

hirify.global provides technology-enabled revenue cycle management and healthcare financial solutions for hospitals and affiliated physician groups.

What you will do

• Conduct medical necessity reviews for admissions, continued stays, inpatient and observation cases using approved clinical criteria.
• Identify over- and under-utilization, patient-care barriers, and opportunities to improve levels of care.
• Coordinate denial appeals and physician-to-physician reviews with physicians, physician advisors, financial clearance, and revenue cycle teams.
• Track denial updates, overturned days, readmissions, denial trends, and related documentation.
• Maintain ConnectCare and ADT work queues and accurately record clinical and revenue cycle data.
• Educate physicians, nurses, care managers, and other stakeholders on utilization review, non-coverage, and payer requirements.

Requirements

• Current unrestricted RN license and current RN compact license required.
• Bachelor’s degree or equivalent experience in nursing or a related field.
• At least 5 years of acute care clinical experience, 2 years of utilization review experience, and 1 year of denial management experience.
• Demonstrated proficiency with InterQual and MCG criteria, plus experience with Epic EMR.
• Knowledge of CMS guidelines, medical necessity criteria, quality improvement processes, and payer requirements.
• Strong critical thinking, clinical judgment, communication, organization, time management, and independent working skills.

Culture & Benefits

• Monday–Friday schedule from 8:30 a.m. to 5:00 p.m., with occasional weekend coverage.
• Remote work with high-speed internet access and required availability for online or onsite meetings and training.
• Comprehensive healthcare, time off, retirement, and well-being benefits.
• Paid professional certifications, tuition reimbursement, career advancement, and incentive programs.
• Culture focused on collaboration, innovation, work-life flexibility, and continuous improvement.