Utilization Review Nurse - RN (Medical)

TL;DR

Utilization Review Nurse - RN (Medical): Evaluating requested medical services against benefit language and evidence-based criteria with an accent on clinical judgment and regulatory compliance. Focus on analyzing clinical records, managing urgent caseloads, and ensuring defensible medical necessity determinations.

Location: Remote (United States)

Compensation: $30.00–$38.00 per hour

Company

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

What you will do

• Conduct medical-necessity reviews using MCG, NCCN, and medical policies to determine appropriate levels of care.
• Route non-certifications to the Medical Director, ensuring adverse determinations meet NCQA/URAC standards.
• Analyze clinical documentation to identify acuity, risk indicators, and inconsistencies.
• Manage a caseload prioritized by urgency and regulatory deadlines.
• Prepare clinical summaries and coordinate peer-to-peer discussions for the appeals process.
• Document all review rationales and outcomes in UM systems to maintain a clean audit trail.

Requirements

• Current, unrestricted RN license in the United States or a U.S. territory.
• Graduate of an accredited nursing program (ADN or diploma required; BSN preferred).
• 1-2+ years of recent clinical experience in acute care, med-surg, ICU/ED, or similar settings.
• Proficiency with MS Office and working knowledge of ICD-10, CPT, and HCPCS coding.
• Availability to work Monday–Friday, 8:00 AM–5:00 PM Pacific Time, including rotating Saturdays.

Nice to have

• Experience in utilization review or utilization management.

Culture & Benefits

• Comprehensive medical and dental benefits effective from day one.
• Paid Time Off (PTO) to ensure rest and recharge.
• Mental health support, retirement planning, and financial protection.
• Professional development opportunities with clear career progression and learning budgets.
• Mission-driven culture that celebrates diversity and equity.