Clinical Guide Part A: Utilization Management Nurse (Inpatient, Behavioral Health & Post-Acute)

Location: Remote USA. Full-time remote work across five 8-hour days; most schedules include one weekend day. Available schedules include Tuesday–Saturday, Sunday–Thursday, and Monday–Friday shifts aligned to Eastern Time.

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 the health and well-being of older Americans.

What you will do

• Conduct prospective, concurrent, and retrospective utilization reviews for inpatient, behavioral health, and post-acute services.
• Evaluate medical necessity, level of care, treatment plans, timing, setting, and length of stay using clinical criteria and CMS guidelines.
• Perform admission, concurrent, discharge, and post-acute reviews for SNF, LTACH, ARU, and home health services.
• Refer cases that do not meet criteria to the Medical Director and prepare clinical summaries for peer-to-peer discussions and final determinations.
• Issue NOMNC when post-acute coverage criteria are no longer met and manage authorization reopen requests.
• Maintain accurate documentation while supporting appropriate resource use, member-centered care, and regulatory compliance.

Requirements

• Unrestricted RN license and at least 4 years of clinical experience.
• At least 3 years of experience in utilization review, utilization management, case management, discharge planning, care coordination, or clinical appeals.
• Experience in a health plan, hospital, or post-acute setting.
• Familiarity with CMS regulations and Medicare Advantage requirements or comparable payer coverage experience.
• Experience escalating cases that do not meet criteria and preparing clinical summaries for physician review.
• Ability to work one of the posted schedules, including a weekend day for most schedules; flexibility across multiple schedules is preferred.

Nice to have

• Experience with AI or LLMs.
• InterQual certification.

Culture & Benefits

• 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 for all employees.
• 401(k) program and bonus eligibility for eligible roles.
• Collaborative, supportive, and inclusive work environment.