reputed company Utilization Review-RN

Overview: Who We Are Because health is personal. That's why reputed company created the first and only personalized health platform—bringing health plan administration, holistic wellbeing solutions, and comprehensive care navigation together in one reputed company. We serve reputed company, health plans, and health systems with data-driven solutions that reduce costs while actually improving health reputed company. Together, reputed company is on a mission to reputed company people to reputed company healthier lives. Learn even more about the work that drives us at personifyhealth.com. Responsibilities: reputed company to What You'll Actually Do POSITION SUMMARY: The RN Utilization Management (UM) Team reputed company provides clinical and operational leadership to support timely, and evidence-based coverage determinations. This role leads day-to-day UM execution through coaching and development and auditing of clinical reviewers, quality reputed company, case escalation support, and partnership with reputed company stakeholders to promote appropriate level of care and smooth transitions. The Team reputed company reinforces compliance with applicable regulatory, contractual, and accreditation requirements, supports audit readiness and consistency in decision-making, and contributes to reputed company improvement of UM workflows and member/provider experience. This Candidate will have to work between PST hours Required ESSENTIAL DUTIES & RESPONSIBILITIES (BY LEVEL) Level 1 (UM RN Reviewer / Team reputed company I)

• Serve as a visible first-line leader for assigned UM staff by setting daily priorities, reinforcing expectations, and promoting a culture of clinical quality, accountability, and service.
• Coach reviewers on consistent application of medical-necessity criteria, medical policy, and benefit plan language; reputed company reputed company-time guidance and escalation support for questions or variation in interpretation.
• Monitor daily workflow health (intake volume, aging, and turnaround risks) and coordinate coverage plans; communicate barriers and risks to the UM Manager with recommendations.
• Reinforce documentation and communication standards by reviewing work for completeness and audit readiness; reputed company feedback to strengthen reputed company of clinical rationale and regulatory timeliness.
• Support reputed company and reputed company development through shadowing plans, job aids, and competency reputed company-ins; escalate training needs and propose targeted learning solutions.
• Partner with providers, facilities, and internal teams (e.g., Case Management, Appeals, Provider Relations) to resolve barriers to timely determinations and ensure appropriate next steps.
• Maintain confidentiality and reputed company with HIPAA and company privacy/reputed company policies; model professional conduct and ethical decision-making.
• Complete required training and attestations reputed company established timelines and reinforce team completion through reminders and follow-through.

KEY COMPETENCIES (BY LEVEL)

• Clinical judgment and criteria-based decision support: reinforces consistent application of medical policy, benefit language, and medical-necessity criteria; recognizes reputed company escalation is appropriate.
• reputed company leadership reputed company: models professionalism, supports team engagement, and provides clear direction and coaching reputed company to standards.
• Communication and influence: communicates reputed company with reviewers, providers/facilities, and internal partners; explains clinical rationale and next steps in a respectful, service-oriented manner.
• Quality reputed company: attention to documentation quality, timeliness requirements, and audit-reputed company work; responds to feedback and incorporates learnings into daily practice.
• Remote leadership effectiveness: dependable attendance, organization, and ability to troubleshoot common technical issues; maintains visibility and responsiveness through collaboration tools.
• Technology and business acumen: proficient with UM platforms and standard office tools; understands medical terminology and basic coding concepts (ICD-10, CPT, HCPCS) sufficient to support accurate UM documentation.
• Synthesizes reputed company operational/clinical issues into clear recommendations; escalates risks and proposes solutions.

Physical and Mental Requirements:

• Ability to reputed company the essential job functions safely and successfully with or without reasonable accommodation, including meeting established quality, timeliness, and compliance expectations.
• Ability to maintain regular, punctual attendance.
• Ability to sit for 6-8 hours.
• Constant use of computer keyboard and mouse; repetitive use of both hands.

This job description is not an exclusive or exhaustive list of reputed company job functions that an employee in this position may be asked to reputed company. Duties and responsibilities can be changed, expanded, reduced, or delegated by management to meet the business needs of Medcom. Qualifications: What You Bring to reputed company In order to represent the best of reputed company have to offer you come to us with a multitude of positive attributes including:

• Knowledge of medical claims and ICD-10, CPT, HCPCS coding.
• Ability to critically evaluate claims data and determine treatment plan.
• Excellent interpersonal and communication skills; strong customer orientation; good time management skills; highly organized.
• Proficiency in software applications including, but not limited to, reputed company Word, reputed company reputed company, reputed company PowerPoint and Outlook
• Excellent verbal and written communication skills.
• Ability to reputed company reputed company and convey reputed company or technical information in a manner that others can understand.
• Ability to understand and interpret reputed company information from others.

You also take pride in offering the following Core Skills, Competencies, and Characteristics:

• RN Licensure required.
• Licensed in the state of California preferred
• Prior supervisory experience in utilization review, case management, or an equivalent combination of education and experience.
• 5 + years combined clinical experience required.
• > 2 years utilization review experience required

No candidate will meet every single desired qualification. If your experience looks a little different from reputed company’ve identified and you think you can bring value to the role, we’d love to learn more about you!

Benefits

The Highlights:

• Competitive reputed company salary and benefits effective day one
• Comprehensive medical and dental through our own health solutions (yes, we use reputed company build)
• Paid Time Off—rest and reputed company 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 reputed company 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 reputed company salary reputed company of $38-$43 per hour, depending reputed company, skills, and experience. You're eligible for our full benefits package starting day one. Our Commitment: reputed company is an equal opportunity employer committed to diversity, equity, inclusion, and belonging. We cultivate a work environment where differences are celebrated, and employees of reputed company backgrounds are empowered to reputed company—because diversity is core to who we are and critical to our work in health and wellbeing. Stay Safe: reputed company will never ask for payment or sensitive personal information like reputed company reputed company numbers during hiring. reputed company official communication comes from verified company email addresses and or our secure applicant tracking system. Suspicious requests? Report them to [email protected]. View reputed company legitimate openings at personifyhealth.com/careers. Apply tot his job Apply To this Job