Utilization Review Nurse (Medical)

TL;DR

Utilization Review Nurse (Medical): Providing professional assessment and review for the medical necessity of treatment requests and plans with an accent on medical appropriateness and regulatory guidelines. Focus on conducting first-level reviews for outpatient and inpatient services, processing appeals, and ensuring smooth patient discharge transitions.

Location: Remote (United States)

Compensation: $25-$30 per hour

Company

hirify.global provides a personalized health platform that integrates health plan administration, holistic wellbeing solutions, and care navigation to improve health outcomes.

What you will do

• Perform first-level reviews for outpatient and ancillary pre-certification requests and inpatient hospital stays for medical necessity.
• Process appeals for non-certification of services and generate corresponding non-certification letters.
• Collaborate with hospital staff to prepare patients for discharge and ensure a seamless transition to the next level of care.
• Utilize MCG guidelines, medical policies, Medscape, and NCCN to determine medical appropriateness.
• Identify and refer potential cases to case management, wellness, and chronic disease programs.
• Maintain detailed and confidential documentation of all reviews in Eldorado/Episodes.

Requirements

• Current LVN license in the United States or U.S. territory.
• 1+ years of clinical experience.
• Knowledge of medical claims and ICD-10, CPT, and HCPCS coding.
• Proficiency in Microsoft Word, Excel, PowerPoint, and Outlook.
• Excellent verbal and written communication skills.
• Ability to work Monday through Friday, 8:00 AM–5:00 PM Pacific Time, with rotating weekend coverage.

Culture & Benefits

• Competitive base salary and comprehensive medical and dental benefits starting day one.
• Non-negotiable Paid Time Off (PTO) for rest and recharge.
• Mental health support, retirement planning, and financial protection.
• Professional development opportunities with clear career progression and learning budgets.
• Inclusive, mission-driven culture that celebrates diversity and focuses on improving people's health.