Nurse - Clinical Review

Location: Remote within the United States; U.S. state or territory nursing license required. Training is Monday to Friday, 8:00 AM–4:30 PM CST for the first six weeks; the regular schedule is 10:30 AM–7:00 PM CST.

Base salary: $65,000 annually for LVN/LPN or $75,000 annually for RN. Performance-based bonuses, incentive pay, or commissions may also apply.

Company

hirify.global is an AI-powered intelligent operations and transformation company serving clients across healthcare, insurance, financial services, logistics, travel, and other industries.

What you will do

• Perform utilization and clinical reviews to determine whether requests meet medical necessity criteria.
• Apply medical policies, NCD/LCD guidelines, and applicable state, federal, and client requirements.
• Resolve escalated cases and communicate with providers, members, physicians, and internal staff by phone as needed.
• Support Physician Reviewers and Medical Directors while meeting defined review timeframes.
• Document reviews accurately and identify quality issues for Nursing Management and UM Leadership.
• Use healthcare software and computer systems to manage cases and participate in the HealthHelp Quality Management Program.

Requirements

• Graduate of an accredited nursing school with an RN or LPN/LVN qualification.
• Current, active, unrestricted RN or LPN/LVN license in a U.S. state or territory.
• At least two years of experience in utilization review, case management, or clinical quality improvement.
• Working knowledge of insurance terminology, National Coverage Determinations, and Local Coverage Determinations.
• Proficiency with Microsoft Word, Excel, and PowerPoint, plus the ability to adapt to healthcare-specific software.
• Strong written and verbal communication, critical thinking, organization, time management, and independent work skills.

Nice to have

• Experience with state and federal regulatory and compliance standards.

Culture & Benefits

• Full-time employment with a remote work arrangement.
• Work within a respectful, diverse, cooperative, and team-oriented environment.
• Base pay may be supplemented by performance-based bonuses, incentive pay, or commissions.
• Work must comply with HIPAA, URAC, NCQA, and applicable state and federal regulations.

Hiring process

• Submit a resume and optional cover letter through the careers page or by email.