Utilization Management (UM) Registered Nurse (RN)

Job Description

Utilization Management (UM) Registered Nurse (RN)

Lead I - BPM

Who We Are

UST HealthProof is a dynamic company with a mission to lower the cost of care and deliver the future of healthcare. Our consumer-centric approach gives our health plan customers a modern infrastructure and reduced administrative costs, helping to drive better business results for our customers — and better outcomes for our communities.

We achieve this mission together through teamwork, communication, collaboration, and focus. Our employees are our greatest assets, and we invite you to apply to be a part of our journey toward making a difference in healthcare in the United States. **

You Are**

UST HealthProof is searching for a UM RN w/an unrestricted RN license who will independently take customer support calls effectively and efficiently; follow the SOPs to complete the process and endeavor to resolve the issue, handle some escalated issues, or escalate to a more knowledgeable person to resolve, in alignment with SLAs and assists Lead I – BPM. A Data Associate should independently be able to effectively and efficiently process the transactions assigned in a timely manner, clarify complex transactions to others, and ensure that quality of output and accuracy of information is maintained, in alignment with SLAs, and assists Lead I – BPM. **

The Opportunity**

• Perform prospective, concurrent, and retrospective reviews of inpatient, outpatient, ambulatory, and ancillary services to ensure medical necessity, appropriate length of stay, the intensity of service, and level of care, including appeal requests initiated by providers, facilities, and members.
• Review, research, and prepare documentation related to retrospective review requests and appeals in accordance with local, state, and federal regulatory and designated accreditation (e.g., NCQA) standards.
• Contact appropriate medical and support personnel to identify and recommend an alternative treatment, service levels, length of stays, etc. using approved clinical protocols.
• Follow out-of-area/out-of-network services and make recommendations on patient transfer to in-network services and/or alternative plans of care.
• May establish care plans and coordinate care through the health care continuum including member outreach assessments.
• Establish, coordinate, and communicate discharge planning needs with appropriate internal and external entities.
• Review patterns of care associated with disease progression; identify contractual services and organize delivery through appropriate channels.
• Research and resolve issues related to benefits, member eligibility, non-elective and non-authorized services, coordination of benefits, and care coordination as needed.
• Develop and deliver targeted education for the provider community related to policies, procedures, and benefits when appropriate.

This position description identifies the responsibilities and tasks typically associated with the performance of the position. Other relevant essential functions may be required. **

What You Need**

• Registered Nurse with current unrestricted Registered Nurse license required.
• 2-4 years of clinical experience which may include acute patient care, discharge planning, case management, utilization review, etc.
• Demonstrated clinical knowledge and experience relative to patient care and healthcare delivery processes. Medicare Advantage experience preferred.
• Excellent written and verbal communication skills.
• Excellent customer service and interpersonal skills.
• Working knowledge of current industry Microsoft Office Suite PC applications.
• Ability to apply clinical criteria/guidelines for medical necessity, setting/level of care, and concurrent patient management.
• Knowledge of current standard medical procedures/practices and their application as well as current trends and developments in medicine and nursing, alternative care settings, and levels of service
• Knowledge of policies and procedures, member benefits, and community resources.
• Knowledge of applicable accreditation standards, and local, state, and federal regulations

Compensation can differ depending on factors including but not limited to the specific office location, role, skill set, education, and level of experience. As required by local law, UST Healthproof provides a reasonable range of compensation for roles that may be hired in California, Colorado, New York or Washington as set forth below. **

Role Location: Remote

Compensation Range:** $42,000-$64,000

Our full-time, regular associates are eligible for 401K matching, and vacation accrual and are covered from day 1 for paid sick time, healthcare, dental, vision, life, and disability insurance benefits. **

What We Believe**

We’re proud to embrace the same values that have shaped UST HealthProof since the beginning. Since day one, we’ve been building enduring relationships and a culture of integrity. And today, it's those same values that are inspiring us to encourage innovation from everyone, to champion diversity and inclusion, and to place people at the center of everything we do. **

Humility**

We will listen, learn, be empathetic and help selflessly in our interactions with everyone. **

Humanity**

Through business, we will better the lives of those less fortunate than ourselves. **

Integrity**

We honor our commitments and act with responsibility in all our relationships. **

Equal Employment Opportunity Statement**

UST HealthProof is an Equal Opportunity Employer.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.

UST HealthProof reserves the right to periodically redefine your roles and responsibilities based on the requirements of the organization and/or your performance.

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