Utilization Review Nurse

Location: Remote within Arizona, Florida, Georgia, Illinois, Iowa, Kansas, Michigan, Missouri, Nebraska, New Jersey, North Carolina, Ohio, Pennsylvania, South Carolina, Tennessee, Texas, or Virginia. Occasional travel may be required for team meetings and company events.

Salary: $35.00–$45.94 per hour

Company

hirify.global is focused on improving the healthcare experience through health insurance and care services.

What you will do

• Complete medical necessity and level-of-care reviews for requested services.
• Review medical records and apply Oscar Clinical Guidelines, Milliman Care Guidelines, or other evidence-based criteria.
• Gather clinical information from members and care providers by telephone and fax.
• Make recommendations on the appropriateness of care for identified diagnoses.
• Meet required decision-making service-level agreements and refer members for additional care engagement when needed.
• Maintain compliance with applicable laws and regulations.

Requirements

• Active, unrestricted US RN license in a listed state or an unrestricted compact multistate RN license under the Nurse Licensure Compact is required.
• Associate degree in nursing, an accredited nursing diploma, or graduation from an accredited school of nursing.
• At least one year of utilization review experience in a managed care setting.
• Strong experience with MCG (Milliman Care Guidelines) or InterQual.
• At least one year of clinical experience, including at least one year of acute-care practice in an emergency room or hospital.
• Weekend availability is required, including at least one working day every Saturday or Sunday.

Nice to have

• BSN degree.
• Experience conducting concurrent or inpatient reviews for a managed care plan.
• Ability to obtain additional state licenses to meet business needs.

Culture & Benefits

• Remote work from a home office within the listed states.
• Employee medical, dental, and vision benefits.
• Paid holidays, sick time, parental leave, and wellness time.
• 401(k) participation, life and disability insurance, and wellness reimbursements.
• Vacation accrual of 15 days per year.