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Utilization Management Nurse

Remote

Our Mission is to Make Healthcare Right. Together. Built upon the belief that by connecting and aligning the best local resources in healthcare delivery with the financing of care, we can deliver a superior consumer experience, lower costs, and optimized clinical outcomes.

What drives our mission? The company values we live and breathe every day. We keep it simple: Be Brave. Be Brilliant. Be Accountable. Be Inclusive. Be Collaborative.

If you share our passion for changing healthcare so all people can live healthy, brighter lives – apply to join our team.

General Purpose

The Utilization Management Nurse is responsible for reviewing requests for pre and post-service authorization(s) and/or payment for both inpatient and or outpatient services for all plan members. The Utilization Management Nurse works in collaboration with the Claims Department and as a liaison with the Utilization and Case Management teams, the Medical Directors, and leadership to assure the timely processing of preauthorizations, medical claims review, provider dispute resolutions, and grievance and appeal requests, to ensure the organizational compliance with CMS and all other rulings, governing and regulatory bodies. Which enables the organization to deliver the highest qualities/standards. The objective of this position is to ensure positive outcomes data and treatment are provided in the most cost-efficient manner without affecting our “Quality of Services”.

Duties and Responsibilities:

• Review pre and post-service payment requests for medical necessity, contract, and regulatory compliance. Referring all determinations to a Medical Director.
• Utilize CMS guidelines (LCD, NCD), Milliman-Roberts, or InterQual guidelines to assist in the determination of referrals.
• Knowledge of CMS Chapter 13
• Maintain goals for established turn-around time (TAT) for referral processing.
• Maintain a professional rapport with providers, physicians, support staff, and patients to review and resolve medical clinical issues as they arise;
• Monitor work queues and Email for incoming requests.
• Verify eligibility and/or benefit coverage for requested services.
• Verify the accuracy of ICD 10 and CPT coding in processing pre-certification requests.
• Contact requesting provider and request medical records, orders, or necessary documentation to process related pre-service requests/authorizations;
• Accurately documents any pertinent determination factors within the referral system.
• Review referral denials for appropriate guidelines and language.
• Assist Medical Directors in reviewing and responding to Appeals and Grievances
• Identify gaps in HCC capture based on clinical review.
• Report gaps to the data team daily.
• Recognize work-related problems and contributes to solutions.
• Meet specific deadlines (responds to various workloads by assigning task priorities according to department policies, standards, and needs).
• Maintain confidentiality of information between and among healthcare professionals.

Experience:

• At least 2 years experience with Medicaid and/or Medicare. 1-2 years experience in a medical setting working with IPAs, entering referrals/prior authorizations.
• Must know ICD-10, CPT codes, Managed Care Plans, medical terminology (certificate preferred), and referral system (Access Express/Portal/N-coder)

Licensures and Certifications:

• An active, unrestricted Registered Nurse (RN) license to practice as a health professional in a state or territory of the United States is required for this role.

We’re Making Healthcare Right. Together.

We are realizing a completely different healthcare experience where payors, providers, doctors, and patients can all feel connected, aligned and unified on the same team. By eradicating the frictions of competing needs, we are making it possible to give everyone more of what they want and deserve. We do this by:

Focusing on Consumers

• We understand patient pain points, eliminating complexity while increasing transparency, for greater access and easier navigation.

Building on Alignment

• We integrate and align inidual incentives at all levels, from financing to optimization to delivery of care.

Powered by Technology

• We employ our purpose built, integrated data platform to connect clinical, financial, and social data, to deliver exceptional outcomes.