Clinical Guide: UM Nurse (Outpatient Prior Authorization)

Location: Remote USA; schedules include Monday–Friday, 10:00 AM–7:00 PM ET, Monday–Friday, 11:00 AM–8:00 PM ET, or Sunday–Thursday, 10:00 AM–7:00 PM ET.

Salary: $82,680–$96,460 per year

Company

hirify.global provides an integrated care platform combining clinical and service experiences with data and AI to improve healthcare for older Americans.

What you will do

• Conduct timely clinical reviews of outpatient authorization requests using evidence-based medical necessity criteria, CMS requirements, Medicare Advantage rules, and health plan policies.
• Review requests for procedures, imaging, therapy, durable medical equipment, and home health services.
• Determine appropriate services and care settings, recommending clinically appropriate alternatives when relevant.
• Escalate cases that do not meet criteria to the Medical Director, prepare clinical summaries, and support peer-to-peer discussions.
• Communicate with providers and internal teams to obtain documentation, resolve clinical questions, and explain coverage information.
• Maintain accurate documentation, meet CMS turnaround standards, and identify potential quality assurance or risk management issues.

Requirements

• Unrestricted RN license and at least 4 years of RN experience.
• At least 3 years of utilization management, utilization review, or prior authorization experience in a health plan, hospital, or post-acute setting.
• Knowledge of CMS guidelines and Medicare Advantage requirements.
• Experience escalating cases and preparing clinical summaries for physician review.
• Ability to work accurately at pace, manage high request volumes, and adapt to changing policies, criteria, and workflows.
• Ability to multitask while listening, speaking, and typing.

Nice to have

• Outpatient prior authorization experience, especially with home health and durable medical equipment.
• Proficiency with Google Workspace and AI tools.
• Ability to explain complex information and adapt communication to different audiences.

Culture & Benefits

• Full-time remote work with five 8-hour days and 40 hours per week.
• Employer-sponsored health, dental, and vision plans with low or no premium.
• Generous paid time off and a parental leave program.
• $100 monthly mobile or internet stipend.
• Stock options and bonus eligibility for eligible full-time roles.
• 401(k) program and a collaborative, supportive work environment.