Utilization Review Clinician

Location: Telecommuter; applicants must be located in one of the listed U.S. states: Alaska, Arizona, Arkansas, California, Colorado, Florida, Georgia, Idaho, Iowa, Kansas, Kentucky, Maine, Michigan, Minnesota, Missouri, Montana, Nevada, New Hampshire, New Mexico, North Carolina, Oklahoma, Oregon, South Carolina, South Dakota, Tennessee, Texas, Utah, Washington, or Wisconsin. Most schedules are Monday–Friday, with some Tuesday–Saturday schedules, from 8:00 a.m. to 5:00 p.m. Pacific Time.

Salary: $80,200–$125,600 national range; $84,200–$143,100 national-plus range for higher-cost labor markets, including Western Washington and Alaska.

Company

hirify.global provides healthcare coverage and services focused on improving customer outcomes and making healthcare work better.

What you will do

• Conduct inpatient, concurrent, retrospective, prior authorization, benefit advisory, out-of-network, and treatment-setting medical necessity reviews.
• Assess requests against clinical criteria, medical policies, member eligibility, benefits, contracts, and InterQual Guidelines.
• Consult with Medical Directors when requests do not meet applicable criteria or policies.
• Document clinical information accurately and meet productivity, quality, and turnaround-time standards.
• Coordinate with Customer Service, Claims Operations, Sales and Marketing, Health Care Services, and other teams to support consistent utilization management workflows.
• Identify clinical program referrals and participate in quality improvement initiatives.

Requirements

• Bachelor’s degree or four years of work experience.
• Current state Registered Nurse license required.
• Three years of clinical experience required.
• Knowledge of provider and member contracts, authorization requirements, clinical criteria, accreditation, and regulatory requirements.
• Work must be performed from one of the specified U.S. states.
• Availability during Pacific Time business hours is required.

Nice to have

• Washington or Compact RN license.
• Utilization review experience.
• Experience in the health plan industry.

Culture & Benefits

• Medical, vision, and dental coverage with low employee premiums.
• Life and disability insurance, retirement programs with a 401(k) match, and a pension plan vested after three years.
• Generous paid time off, wellness resources, counseling, and mindfulness programs.
• Tuition assistance for undergraduate and graduate education.
• Employee recognition programs and opportunities for ongoing learning and career development.