Utilization Management Nurse

Location: Fully remote, based in the United States

Salary: $80,000–$95,000 per year, with final compensation based on experience, skills, and organizational needs.

Company

hirify.global provides healthcare technology for PACE programs, supporting care coordination, risk adjustment, population health, utilization management, financial performance, and compliance.

What you will do

• Review service utilization, claims, and authorizations for medical necessity, care-plan alignment, and compliance with PACE policies.
• Conduct concurrent and retrospective reviews of hospital, observation, inpatient, subacute, and skilled nursing facility admissions.
• Partner with interdisciplinary teams, medical directors, primary care providers, and contracted networks to support timely transitions and discharge planning.
• Maintain accurate records of participant-related interactions and utilization decisions.
• Lead provider appeals by reviewing submissions, collaborating with the Medical Director, and issuing written determinations.
• Advocate for quality care, improved quality of life, and reduced hospital stays when clinically appropriate.

Requirements

• 3–5 years of utilization management experience.
• Current registered nurse license.
• Experience working in risk-based integrated care models.
• Ability to use data to support decisions and collaborate with internal and external stakeholders.
• Strong strategic thinking, problem-solving, decision-making, communication, and leadership skills.
• Must be based in the United States; visa sponsorship is not available.

Culture & Benefits

• Competitive salary and equity package.
• Health, dental, and vision insurance.
• Collaborative, inclusive, and dynamic work environment.
• Professional growth and development opportunities.
• Opportunity to contribute to healthcare technology supporting socially vulnerable and clinically complex seniors.