Utilization Review Nurse - RN

Location: Remote, United States. Schedule: Monday–Friday, 8:00 AM–5:00 PM Pacific Time, with rotating Saturday coverage as required.

Salary: $35.00–$43.00 per hour, depending on location, skills, and experience.

Company

hirify.global provides a personalized health platform combining health plan administration, wellbeing solutions, and care navigation for employers, health plans, and health systems.

What you will do

• Conduct medical-necessity reviews using benefit language, medical policies, and nationally recognized criteria including MCG and NCCN.
• Analyze clinical documentation, identify acuity indicators and gaps, and escalate cases requiring additional review.
• Manage caseloads according to urgency, regulatory deadlines, member impact, and turnaround standards.
• Verify eligibility, benefits, authorizations, and network status to support appropriate in-network care.
• Prepare clinical summaries, coordinate peer-to-peer physician discussions, and route appeals and IRO referrals.
• Document review rationales, criteria citations, outcomes, and audit information while maintaining HIPAA compliance.

Requirements

• Current, unrestricted RN license in the United States or a U.S. territory; compact license accepted where applicable.
• Graduate of an accredited nursing program with an ADN or diploma; BSN preferred.
• 1–2+ years of recent clinical experience in acute care, med-surg, ICU/ED, or a similar setting.
• Working knowledge of ICD-10, CPT, HCPCS coding, medical claims, medical records, and evidence-based criteria.
• Proficiency with Microsoft Word, Excel, and Outlook, with strong typing and ability to work across multiple systems.
• Utilization review or utilization management experience is preferred.

Culture & Benefits

• Full benefits package effective on the first day of employment.
• Comprehensive medical and dental coverage through hirify.global solutions.
• Paid time off, mental health support, retirement planning, and financial protection.
• Professional development, career progression, and learning budgets.
• Mission-driven environment focused on improving health outcomes and valuing diverse perspectives.