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Job Summary
Under the supervision of a registered nurse the Utilization Review Nurse will provide professional assessment and review for the medical necessity of treatment requests and plans. The standard work schedule is Monday through Friday, 8:00 AM–5:00 PM Pacific Time, with rotating weekend coverage as required.
What You'll Actually...
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ESSENTIAL DUTIES and RESPONSIBILITIES:
The Medical Director relies on their medical background to review claims for medical necessity for prior authorization, continued stay review and post service. The Medical Director can read, interpret, and apply medical policy, guidelines, and research to utilization review. The Medical Director has authority for issuing adverse determinations while performing medical necessity evaluation.
- Has discussions with external physicians by phone to gather additional clinical information or discuss determinations regularly, and in some instances, these may require conflict resolution skills. Some roles include an...
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Ready to lead health plan configuration and solution design, driving the full lifecycle of plan build and cross-functional execution across a complex TPA environment?
Personify Health is looking for a Senior Director of Plan Configuration and Documentation to lead the teams responsible for building health plans in our systems and designing enterprise-level solutions for our...
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Ready To
What You'll Actually Do
ESSENTIAL DUTIES AND RESPONSIBILITIES:
The Care Management Manager of Education & Quality is responsible for the development, implementation, and ongoing oversight of regulatory compliance, quality assurance, and training programs across Care Management functions, including...
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Ready To Lead the Team That Sets the Tone for Every Client Relationship?
Why This Role Matters
A client's first experience with Personify Health isn't shaped by promises — it's shaped by how well their implementation goes. As Manager of Implementation Project Management, you'll own that experience at scale: directly managing complex health plan administration...
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Ready To Own the Data Integrity That Keeps Member Eligibility Accurate Across a Complex Benefits Platform?
Why This Role Matters
Eligibility errors don't stay contained — they ripple into claims, coverage gaps, and client escalations. This role is responsible for validating, maintaining, and troubleshooting the eligibility and enrollment data that underpins benefits administration for our clients. The work...
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Ready To Keep Provider Records Accurate So Claims Can Move Without Delays?
Why This Role Matters
Claims can't process cleanly without matched, accurate provider records behind them. This role sits at that junction — pulling claims, locating or creating provider records, and maintaining the data integrity that keeps the claims operation hitting its daily targets. Precision here prevents downstream errors that...
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Ready To Be the First Point of Contact That Keeps Pre-Certification Moving for Members and Providers?
Why This Role Matters
Pre-certification is a critical gateway in the healthcare process — delays or errors here ripple downstream for members and providers alike. This role sits at the front line of that process, routing calls, gathering the right information, and making sure service requests reach the right...
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Job Summary
We are seeking Case Manager Nurse, RN, to join our team. As a Case Manager RN, you will provide telephonic case management between providers, patients and caregivers to help ensure cost-effective, high-quality healthcare for health insurance plan participants. This position offers flexibility and is ideal for candidates looking for reduced hours while making an impact within the team.
What You'll Actually Do
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Ready To Build the Systems That Keep a Complex Organization Running?
Why This Role Matters
In a TPA environment, operational complexity is constant — and the difference between chaos and clarity comes down to how well processes are designed, documented, and governed. The Process Manager is the person who makes that happen. You'll own a cross-functional portfolio of...
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Ready To
What You'll Actually Do
ESSENTIAL DUTIES AND RESPONSIBILITIES:
The Clinical Compliance & Quality Specialist is responsible for ensuring regulatory and quality compliance across clinical operations. This role requires consistent use of independent judgment and discretion in evaluating, auditing, and...
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Ready to Support Client Success Through Expert Coordination and Strategic Problem-Solving?
Why This Role Matters
Account management doesn't happen in a vacuum—it requires coordinated support to ensure client needs are met consistently and issues are resolved before they escalate. As our Account Management Coordinator, you'll serve as product expert and trusted partner during new client onboarding and ongoing service...
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Ready To Keep Legal Operations Running While Supporting Active Litigation From the Inside?
Why This Role Matters
Legal departments move fast and run on precision — missed deadlines and disorganized files have real consequences. This role keeps the operational engine of the legal department running while providing direct, hands-on support to the disputes attorney on active and potential litigation matters....
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Ready To Own the Design System That Defines How Millions of Members Experience Personify Health?
Why This Role Matters
A design system is only as strong as the team and leadership behind it. This role owns the full strategy, architecture, and evolution of Personify Health's cross-platform design system — the foundational layer powering our Angular web platform and native...
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Ready To Keep Claims Moving Accurately for the Members and Clients Who Depend on Every Decision?
Why This Role Matters
Claims processing is where coverage becomes real for members. This role sits at the center of daily claims operations — processing accurately, meeting production targets, and making sure clients receive the reliable service they've contracted for. Errors here have downstream consequences;...
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Ready to deliver end-to-end TPA solutions—aligning client needs, product, and operations across eligibility, claims, and billing?
Why This Role Matters
As a Solutions and Services Architect at Personify Health, you will be an integral part of the TPA team. In partnership with...
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Ready To Build and Lead Engineering Teams That Ship Healthcare Data Products at Scale?
Why This Role Matters
Engineering teams don't run themselves — they need someone who can clear blockers, grow talent, and keep delivery moving without sacrificing quality. This role owns both the people and the execution: managing a team of engineers working across data pipelines, web...
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Ready to Lead Operations and Strategy for a High-Profile Health System Partnership?
Why This Role Matters
This isn't a traditional account leadership role—it's a unique seat requiring both deep clinical expertise and commercial relationship mastery at the executive level. As Senior Director for the Northwell account, you'll own all aspects of this strategic partnership including Member Services, Claims Operations, Account Management teams, and all 100% dedicated...
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Ready to Build Training That Turns New Hires into Confident TPA Member Service Professionals?
Why This Role Matters
Training isn't just onboarding—it's the foundation that determines whether agents handle member calls with confidence or struggle through every interaction. As our Trainer for Member Services Operations, you'll support, maintain, and deliver new hire, product, process, and TPA-specific training that prepares agents to transition successfully to live...
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Ready to Lead Strategic Wellbeing That Transforms Workplace Culture and Employee Health?
Why This Role Matters
Strategic wellbeing programs require more than program execution—they demand comprehensive vision, C-suite engagement, and the ability to design initiatives that reflect diverse workforce needs. As our client-dedicated Health &...