Utilization Management Nurse (Healthcare)

TL;DR

Utilization Management Nurse (Healthcare): Reviewing and managing utilization management activities for plan participants with an accent on clinical appropriateness, regulatory compliance, and cost-effective care. Focus on identifying high-risk cases, coordinating discharge planning, communicating utilization decisions, and addressing quality and patient safety issues.

Location: Fully remote, but must be based in the United States. Work follows standard business hours Monday through Friday, with schedules aligned to EST, CST, MST, or PST time zones.

Company

hirify.global provides integrated healthcare solutions for employers, payers, providers, and members, covering care navigation, care management, payment integrity, plan performance, and provider verification.

What you will do

• Conduct prospective, concurrent, and retrospective utilization management reviews using plan documents and applicable criteria.
• Collaborate with healthcare professionals and internal stakeholders to make timely, appropriate utilization decisions.
• Identify overutilization, underutilization, improper utilization, catastrophic cases, and disease management needs.
• Communicate decisions and recommendations to providers and plan participants while maintaining accurate confidential records.
• Support continuity of care through early discharge planning and escalate quality or patient safety concerns.
• Maintain compliance with CMS, URAC, HIPAA, and other applicable regulatory standards.

Requirements

• 3+ years of clinical nursing experience.
• Active, unrestricted RN license in the state of residence.
• Ability to work independently in a fast-paced, detailed, deadline-driven environment.
• Strong problem-solving, organizational, relationship-building, and communication skills.
• Ability to maintain strict confidentiality and handle sensitive healthcare information.
• Must be US-based and able to comply with HIPAA and company security requirements.

Nice to have

• Utilization Management or Case Management certification.

Culture & Benefits

• Fully remote work with company-provided equipment and a quiet, distraction-free workspace.
• Reliable internet connection and adherence to VPN, secure password, and approved device policies.
• Medical, dental, and vision insurance with company subsidies.
• HSA, FSA, DCFSA, and a 401(k) with company match and immediate vesting.
• Paid vacation, sick leave, holidays, maternity and paternity leave.
• Employee assistance, pet insurance, discounts, and paid time off for community and philanthropic activities.