Lead Utilization Review - RN

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

Salary: $38–$44 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

• Set daily priorities and performance expectations for the utilization management team.
• Coach reviewers on medical-necessity criteria, medical policy, and benefit-plan interpretation.
• Monitor intake volume, aging cases, turnaround risks, and workflow barriers.
• Audit documentation for completeness, clinical rationale, regulatory timeliness, and audit readiness.
• Build reviewer capability through shadowing plans, job aids, competency checks, and targeted training.
• Partner with providers, facilities, Case Management, Appeals, and Provider Relations to resolve barriers while maintaining HIPAA and privacy standards.

Requirements

• Active RN license.
• Experience in utilization management, clinical review, or case management.
• Experience applying medical-necessity criteria and interpreting benefit plans in a healthcare payer or clinical review setting.
• Proficiency with utilization management platforms and standard productivity tools.
• Working knowledge of medical terminology and coding concepts, including ICD-10, CPT, and HCPCS.
• Ability to work remotely from the United States and maintain Pacific Time schedule coverage.

Culture & Benefits

• Full benefits package effective from day one.
• 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.