Nurse - Clinical Review (Utilization Review)

Location: Remote within the United States; an active, unrestricted RN, LPN, or LVN license in a U.S. state or territory is required. Training schedule: Monday–Friday, 8:00 AM–4:30 PM CST for the first six weeks; regular schedule: 10:30 AM–7:00 PM CST.

Salary: $65,000 annually for LVN/LPN; $75,000 annually for RN. Additional performance-based bonuses, incentive pay, or commissions may apply.

Company

hirify.global is a large intelligent operations and transformation company using AI-powered platforms and analytics across healthcare and other industries.

What you will do

• Perform utilization reviews to determine whether requests meet medical necessity criteria under client medical policies and applicable regulations.
• Conduct clinical reviews within required state, federal, client, URAC, and NCQA timeframes.
• Resolve escalated cases and communicate with providers, physicians, members, administrative staff, and internal teams.
• Document case reviews, identify quality issues, and refer them to utilization management leadership.
• Support Physician Reviewers and Medical Directors in maintaining review-timeframe compliance.
• Use healthcare software and computer systems to manage cases, document decisions, and participate in quality management activities.

Requirements

• Graduate of an accredited nursing school with an RN, LPN, or LVN qualification.
• Current, active, unrestricted RN, LPN, or LVN license in a U.S. state or territory.
• At least two years of experience in utilization review, case management, or clinical quality improvement.
• Working knowledge of National Coverage Determinations, Local Coverage Determinations, and insurance terminology.
• Experience applying critical thinking, organizational, time-management, and communication skills independently and under pressure.
• Proficiency with Microsoft Word, Excel, PowerPoint, and healthcare-specific software systems.

Nice to have

• Experience with state and federal regulatory and compliance standards.

Culture & Benefits

• Remote work arrangement with fixed CST working hours.
• Opportunity to work with healthcare providers, administrative personnel, and clinical leadership.
• Inclusive environment focused on teamwork, respect, diversity, and cooperation.
• Eligibility for performance-based bonuses, incentive pay, or commissions in addition to base salary.
• Reasonable accommodations are provided for disabilities and sincerely held religious beliefs.

Hiring process

• Submit a resume and optional cover letter through the careers page or by email.