3401-UM Nurse Reviewer

About the Role

We are looking for a Utilization Management (UM) Nurse Reviewer to bring clinical expertise into our AI-powered prior authorization workflows. This role is responsible for ensuring that our AI- powered prior authorization workflow reflects evidence-based and payer-specific guidelines.

The ideal candidate will have broad experience across multiple specialties and payer policies, with strong utilization management and prior authorization expertise. This role blends clinical judgment with hands-on review of AI outputs to improve accuracy and alignment with payer criteria.

A Day in the Life

• Apply clinical judgment to ensure outputs align with payer requirements, evidence-based guidelines, and coding standards.
• Monitor payer updates and guideline changes; ensure payer knowledge base remains current.
• Collaborate with product, engineering, and AI teams to translate clinical and utilization review requirements into actionable design.
• Test, validate, and refine AI-powered workflows to improve completeness, reduce denials, and ensure usability.
• Provide feedback loops to enhance knowledge base structure, clinical decision support, and automation quality.
• Stay current on payer requirements, clinical guidelines, regulatory standards, and coding updates relevant to utilization management.

 What You Need

• Registered Nurse (RN) with an active license.
• 5+ years of experience in utilization management, prior authorization  or medical policy review.
• Broad exposure across multiple specialties (e.g., radiology, oncology, surgery, cardiology).
• Strong understanding of payer policies, medical necessity criteria, and authorization workflows.
• Working knowledge of ICD-10, CPT, and HCPCS coding.
• Comfort with technology platforms; interest in AI or decision support systems.
• Strong analytical and critical thinking skills with attention to detail.
• Clear communication skills to bridge clinical and technical teams.

Preferred Skills

• Certification in medical coding (e.g., CPC, CCS, CCA, or equivalent).
• Prior experience reviewing or implementing payer medical policies.
• Familiarity with health informatics or  evidence-based guideline development
• Experience working with AI, automation tools, or clinical decision support systems.
• Ability to work in a fast-paced, innovative environment and contribute to process improvement.

We offer competitive benefits to set you up for success in and outside of work.

Here’s What We Offer

• Generous Paid Time Off: Recharge and relax with 22 days of fixed time off per year, in addition to company holidays—because we believe work-life balance fuels performance.
• Best-in-Class Parental Leave: Spend quality time with your growing family. We offer one of the industry’s most generous parental leave policies to support you during life’s most important moments.
• Recognition & Rewards: We celebrate wins—big and small. Get rewarded with monetary incentives and company-wide recognition for your impact and dedication. Your hard work won’t go unnoticed.
• Comprehensive Insurance Coverage: Stay covered with medical, dental, and vision insurance, plus 100% company-paid short- and long-term disability and basic life insurance. Optional perks include discounted legal aid and pet insurance.

Innovaccer Inc. is an equal opportunity employer. We celebrate diversity and are committed to fostering an inclusive workplace where all employees feel valued and empowered regardless of any characteristic protected by federal, state or local law including, without limitation, race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, medical condition, disability, age, marital status, or veteran status. Innovaccer Inc. participates in the E-Verify program to confirm employment eligibility of all newly hired employees based out of the U.S. and employed by Innovaccer Inc.

For any additional information, please visit the below websites:

E-Verify

Right to Work (English)

Right to Work (Spanish)

Disclaimer: 

Innovaccer does not charge fees or require payment from individuals or agencies for securing employment with us. We do not guarantee job spots or engage in any financial transactions related to employment. If you encounter any posts or requests asking for payment or personal information, we strongly advise you to report them immediately to our HR department at [email protected]. Additionally, please exercise caution and verify the authenticity of any requests before disclosing personal and confidential information, including bank account details.