Lead Utilization Review - RN
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What you'll do
- Set daily direction for your UM team: Establish priorities, reinforce expectations, and build a culture where clinical quality and accountability are the norm, not the exception.
- Coach reviewers on criteria application: Guide consistent use of medical-necessity criteria, medical policy, and benefit language, and step in with real-time answers when interpretations vary.
- Monitor workflow health daily: Track intake volume, aging cases, and turnaround risk; flag barriers to the UM Manager with a recommendation attached, not just a problem.
- Audit for documentation quality: Review reviewer work for completeness and audit readiness, then coach for sharper clinical rationale and tighter regulatory timeliness.
- Build reviewer capability: Run shadowing plans, job aids, and competency check-ins for new and existing staff; identify training gaps and propose solutions before they become bigger problems.
- Resolve cross-team barriers: Partner with providers, facilities, Case Management, Appeals, and Provider Relations to clear roadblocks and keep determinations moving.
- Protect member and company data: Maintain HIPAA compliance and company privacy standards, and model the ethical decision-making you expect from your team.
- Drive training completion: Complete required training and attestations on time, and keep your team on track to do the same.
What they're looking for
- Active RN license
- Experience in utilization management, clinical review, or case management
- Background applying medical-necessity criteria and benefit plan interpretation in a healthcare payer or clinical review setting
- Proficiency with UM platforms and standard office/productivity tools
- Working knowledge of medical terminology and coding concepts (ICD-10, CPT, HCPCS) sufficient to support accurate UM documentation
- Familiarity with remote collaboration tools for team visibility and responsiveness
Summarised by NextRaise from the employer’s description, which follows in full below.
Full description from employer
Overview
Who We Are
Because health is personal. That's why Personify Health created the first and only personalized health platform—bringing health plan administration, holistic wellbeing solutions, and comprehensive care navigation together in one place. We serve employers, health plans, and health systems with data-driven solutions that reduce costs while actually improving health outcomes. Together, our team is on a mission to empower people to lead healthier lives.
Learn even more about the work that drives us at personifyhealth.com.
Responsibilities
Ready to lead the clinical team that keeps care moving when it matters most?
Why This Role Matters
Every delayed or unclear coverage decision is a person waiting on care they need. The RN UM Team Lead makes sure that doesn't happen — coaching reviewers to apply medical-necessity criteria consistently, catching risk before it becomes a backlog, and keeping documentation audit-ready so decisions hold up under scrutiny. This isn't a background role: it's the difference between a member getting a timely answer and getting stuck in a queue. You're the person providers and internal teams turn to when a case gets complicated and needs a clear path forward. When your team runs tight, members get faster answers, providers get fewer headaches, and the business stays compliant — that's the job.
Schedule: Monday–Friday, 8:00 AM–5:00 PM Pacific Time, with rotating Saturday coverage as required.
What You'll Actually Do
- Set daily direction for your UM team: Establish priorities, reinforce expectations, and build a culture where clinical quality and accountability are the norm, not the exception.
- Coach reviewers on criteria application: Guide consistent use of medical-necessity criteria, medical policy, and benefit language, and step in with real-time answers when interpretations vary.
- Monitor workflow health daily: Track intake volume, aging cases, and turnaround risk; flag barriers to the UM Manager with a recommendation attached, not just a problem.
- Audit for documentation quality: Review reviewer work for completeness and audit readiness, then coach for sharper clinical rationale and tighter regulatory timeliness.
- Build reviewer capability: Run shadowing plans, job aids, and competency check-ins for new and existing staff; identify training gaps and propose solutions before they become bigger problems.
- Resolve cross-team barriers: Partner with providers, facilities, Case Management, Appeals, and Provider Relations to clear roadblocks and keep determinations moving.
- Protect member and company data: Maintain HIPAA compliance and company privacy standards, and model the ethical decision-making you expect from your team.
- Drive training completion: Complete required training and attestations on time, and keep your team on track to do the same.
Qualifications
What You Bring to Our Team
What You Bring to Our Team
Education & Experience:
- Active RN license
- Experience in utilization management, clinical review, or case management
- Background applying medical-necessity criteria and benefit plan interpretation in a healthcare payer or clinical review setting
Technical Skills:
- Proficiency with UM platforms and standard office/productivity tools
- Working knowledge of medical terminology and coding concepts (ICD-10, CPT, HCPCS) sufficient to support accurate UM documentation
- Familiarity with remote collaboration tools for team visibility and responsiveness
Benefits
The Highlights:
- Competitive base salary and benefits effective day one
- Comprehensive medical and dental through our own health solutions (yes, we use what we build)
- Paid Time Off—rest and recharge time is non-negotiable
- Mental health support, retirement planning, and financial protection
- Professional development with clear career progression and learning budgets
- Mission-driven culture where diverse perspectives drive real impact on people's health
Want the full picture? Visit personifyhealthbenefits.com to explore our complete benefits package, wellness programs, and other employee perks.
Compensation: This position offers a base salary range of $38-$44 per hour, depending on location, skills, and experience. You're eligible for our full benefits package starting day one.
Our Commitment: Personify Health is an equal opportunity employer committed to diversity, equity, inclusion, and belonging. We cultivate a work environment where differences are celebrated, and employees of all backgrounds are empowered to thrive—because diversity is core to who we are and critical to our work in health and wellbeing.
Stay Safe: Personify Health will never ask for payment or sensitive personal information like social security numbers during hiring. All official communication comes from verified company email addresses and or our secure applicant tracking system. Suspicious requests? Report them to talent@personifyhealth.com. View all legitimate openings at personifyhealth.com/careers.
Company
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