Who We Are

Ready to create a healthier world? We are ready for you! 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.

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What You'll Actually Do

ESSENTIAL DUTIES and RESPONSIBILITIES:

Responsible for the overall clinical aspects of the Care Management Team.

· Supervise Utilization Review (UR), Chronic Disease Management (DM) and/or Case Management (CM) team personnel including participating in interviewing, hiring, and training employees; plan, assign, and direct work; appraise performance; rewarding and disciplining employees; addressing complaints and resolving problems.

· Keep team informed of clinical updates, compliance related issues and policies.

· Work with the VP of Care management to establish work procedures and processes that support company and departmental standards, procedures, and strategic directives.

· Use appropriate judgment in upward communication regarding department or employee concerns.

· Maintain and improve UR, DM, and CM teams operations by monitoring system performance; identify and resolve problems; audit and analyze staff performance; prepare and complete action plans; assist in managing system and process improvement and quality assurance programs as it relates to clinical management and plan language interpretation.

· Oversee the negotiation and implementation of cost management strategies to affect quality outcomes and reflect this data in monthly case management reviews as it relates to clinical aspects.

· 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 period.

· Ability to communicate with external sponsors and vendors and to communicate clearly about the programs that are offered by the company internally and externally.

· Ability to create, teach and present information to internal and external audiences with varying backgrounds and cultures

KEY COMPETENCIES:

To work in the health industries and to work remotely, it has been demonstrated that those with computer skills work better in these remote job descriptions.

UPON HIRE, must have:

· Basic computer literacy

· The ability to work on multiple screens, and proficient typing skills.

· Proficiency in software applications including, but not limited to, Microsoft Word, Microsoft Excel, and Outlook Excellent verbal and written communication skills

· Ability to speak clearly and convey complex or technical information in a manner that others can understand, as well as the ability to understand and interpret complex information from others.

· Ability to work independently and utilize written resources to solve problems.

After training with our training department and 1.5 months ramp (3 months total), must have and be able to work in:

o Teams on and off camera, SharePoint, Drives as needed, VPN, UM Web or Health Notes, El Dorado, Quick Links, GIAS, ADP, Confluence, Phone system with headset, Smartsheet—there may be additional programs as it relates to job duties

· Knowledge of medical claims and ICD-10, CPT, HCPCS coding

· Excellent verbal and written communication skills for upward and downward conversations

· Microsoft Office and other computer skills and ability to learn and help guide software development

· Flexible and able to prioritize day-to-day position requirements

· Strategic thinking with proven ability to communicate a vision and drive results

· Proficient in analysis and interpretation of clinical data

· Comfortable with multiple accountabilities and matrix management

· Proven record of strong relationships and working with diverse teams

· Demonstrated ability to work independently with excellent judgment

· Strong interpersonal skills necessary to effectively communicate with medical personnel and members

· Analytical and problem-solving skills necessary to identify and review pertinent information

· The ability to incorporate analytical data into new or existing clinical programs to enhance quality of care

· Ability to maintain an extremely elevated level of confidentiality

· Able to successfully handle competing priorities

· Experience in the Utilization Review Process which includes Prior-Authorization/Pre-Certification, Retro Reviews, Concurrent Reviews and Post Service Claims Review

· Experience in disease management and know and understand disease progression

· Knowledgeable of the Federal, State and ERISA regulations

What You Bring to Our Mission

· Associate Degree of Nursing plus 3 years mgt. experience and/or Bachelor Degree of Nursing RN

· Licensure in California required.

· Master’s degree of Nursing preferred

· Certification in Case Management or Utilization Review a plus.

· Minimum 5 years of Utilization Review, Case Management, Chronic Disease Management, and/or Hospital experience required.

· Minimum 3 years of compliance related experience preferred.

· Experience working in sales, with groups, Medicaid, Medicare, fully insured, HMO and Self Insured preferred

· Managed Care management experience preferred in UR, CM, DM

Physical and Mental Requirements:

· Ability to perform the essential job functions safely and successfully with or without reasonable accommodation, including meeting qualitative and/or quantitative productivity standards.

· Ability to maintain regular, punctual attendance.

· Ability to sit for 6-8 hours.

· Ability to travel throughout the United States and external countries.

· Constant use of computer keyboard and mouse; repetitive use of both hands.

· Occasional to frequent twisting of neck; occasional bending of neck and at waist.

Why You'll Love It Here

We believe in total rewards that actually matter—not 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 one—because you shouldn’t have to wait to be taken care of

Ready to create a healthier world? We're ready for you.

No candidate will meet every single desired qualification. If your experience looks a little different from what we’ve identified and you think you can bring value to the 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 $118,560-$137,280. Note that compensation may vary based on location, skills, and experience. This position is eligible for health, dental, vision, mental health and other 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.

#WeAreHiring #PersonifyHealth #TPA #HPA #Selffunded

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.

Application Deadline: Open until position is filled.