Ready to create a healthier world? Personify Health is on a mission to simplify and personalize the health experience to improve health and reduce costs for companies and their people. At Personify Health, we believe in offering total rewards, flexible opportunities, and a diverse inclusive community, where every voice matters. Together, we're shaping a healthier, more engaged future.
Provide professional assessment and review for the medical necessity of treatment requests and plans.
Provide first level review for all outpatient and ancillary pre-certification requests for medical appropriateness; inpatient hospital stay including mental health, substance abuse, skilled nursing, and rehabilitation for medical necessity; and post claim or post service reviews. Staff are expected to cross train, and provide cross coverage as needed.
Work to the top of the RN license and ensure proper referral to medical director for denial authorizations through independent review organizations (IRO).
Work with hospital staff to prepare patients for discharge and ensure a smooth transition to the next level of care.
Refer requests that fall outside of established guidelines to advance review or senior care consultants.
Process appeals for non-certification of services, complete non-certification letters when appropriate.
Review plan document for benefit determinations; attempt to redirect providers and patients to PPO providers.
Identify and refer potential cases to case management, wellness, chronic disease and Nurturing Together programs.
Complete documentation for all reviews in appropriate documentation software.
Utilize guidelines in appropriate hierarchy. Guidelines include MCG guidelines, internal medical policies, group specific policies, and NCCN.
Ability to meet productivity, quality, and turnaround times daily.
Ability to pass external audits to include URAC and NCQA.
Maintain HIPPA compliance per company's policy and procedures.
Maintain confidentiality and minimum requirement rules.
Complete all required yearly training per company's expected time limit.
Complete and pass all annual testing including IRRA at 90% or higher.
Current RN license in the United States or U.S. territory.
Associate's degree or diploma (Nursing program) required.
1+ year clinical experience required.
Required Knowledge, Skills, and Abilities
We believe in total rewards that actually matternot just competitive packages, but benefits that support how you want to live and work.
Your wellbeing comes first:
Comprehensive medical and dental coverage through our own health solutions (yes, we use what we build!)
Mental health support and wellness programs designed by experts who get it
Flexible work arrangements that fit your life, not the other way around
Financial security that makes sense:
Retirement planning support to help you build real wealth for the future
Basic Life and AD&D Insurance plus Short-Term and Long-Term Disability protection
Employee savings programs and voluntary benefits like Critical Illness and Hospital Indemnity coverage
Growth without limits:
Professional development opportunities and clear career progression paths
Mentorship from industry leaders who want to see you succeed
Learning budget to invest in skills that matter to your future
A culture that energizes:
People Matter: Inclusive community where every voice matters and diverse perspectives drive innovation
One Team One Dream: Collaborative environment where we celebrate wins together and support each other through challenges
We Deliver: Mission-driven work that creates real impact on people's health and wellbeing, with clear accountability for results
Grow Forward: Continuous learning mindset with team events, recognition programs, and celebrations that make work genuinely enjoyable
The practical stuff:
Competitive base salary that rewards your success
Unlimited PTO policy because rest and recharge time is non-negotiable
Benefits effective day onebecause you shouldn't have to wait to be taken care of
Ready to create a healthier world while building the career you want? We're ready for you.
No candidate will meet every single qualification listed. If your experience looks different but you think you can bring value to this role, we'd love to learn more about you.
Personify Health is an equal opportunity organization and is committed to diversity, inclusion, equity, and social justice.
In compliance with all states and cities that require transparency of pay, the base compensation for this position ranges from $30.38 to $37.98 per hour. Note that compensation may vary based on location, skills, and experience. This position is part time and therefore not eligible for benefits.
We strive to cultivate a work environment where differences are celebrated, and employees of all backgrounds are empowered to thrive. Personify Health is committed to driving Diversity, Equity, Inclusion and Belonging (DEIB) for all stakeholders: employees (at each organization level), members, clients and the communities in which we operate. Diversity is core to who we are and critical to our work in health and wellbeing.
Application Deadline: 11/3 or until qualified applicants are received
#WeAreHiring #PersonifyHealth
Beware of Hiring Scams: Personify Health will never ask for payment or sensitive personal information such as social security numbers during the hiring process. All official communication will come from a verified company email address. If you receive suspicious requests or communications, please report them to talent@personifyhealth.com. All of our legitimate openings can be found on the Personify Health Career Site.