Lead Utilization Review RN

TL;DR

Lead Utilization Review RN (Healthcare Utilization Management): Leading a remote clinical review team that applies medical-necessity criteria and benefit policies to support timely, compliant care decisions with an accent on reviewer coaching, workflow oversight, and audit-ready documentation. Focus on resolving complex coverage cases, managing turnaround risks, strengthening clinical rationale, and maintaining HIPAA-compliant operations.

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

Salary: $38.00–$44.00 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

• Set daily priorities and reinforce clinical quality and accountability across the utilization management team.
• Coach reviewers on medical-necessity criteria, medical policies, benefit language, and complex case interpretation.
• Monitor intake volume, case aging, turnaround risks, and workflow barriers, escalating issues with recommendations.
• Audit documentation for completeness, clinical rationale, regulatory timeliness, and audit readiness.
• Develop shadowing plans, job aids, competency checks, and training solutions for reviewers.
• Partner with providers, facilities, Case Management, Appeals, and Provider Relations to resolve barriers and keep determinations moving.

Requirements

• Active RN license required.
• 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 ICD-10, CPT, and HCPCS coding concepts.
• Ability to work remotely within the United States and align with the Pacific Time schedule, including rotating Saturday coverage.

Culture & Benefits

• Full benefits package available 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, inclusive environment focused on improving health outcomes.