Job Description
Behavioral Health - Utilization Review – RN
Lead II – 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**
Telephonic coordination and delivery of clinical behavioral health services designed to meet the wellness and recovery needs of the consumer. In addition to performing prospective, concurrent, and retrospective reviews of inpatient, outpatient, ambulatory, and ancillary services to ensure medical necessity, appropriate length of stay, intensity of service, and level of care, including appeal requests initiated by providers, facilities, and members. May establish care plans and coordinate care through the health care continuum. This candidate will utilize clinical skills to coordinate, document, and communicate all aspects of the utilization/benefit management program. **
The Opportunity**
- Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor, and evaluate options to facilitate appropriate healthcare services/benefits for members.
- Review, research, and authorize requests for authorization of elective, direct, ancillary, urgent, emergency, etc. services.
- Contact appropriate medical and support personnel to identify and recommend alternative treatment, service levels, length of stays, etc. using approved clinical protocols.
- Analyze, research, respond to, 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.
- Establish, coordinate, and communicate discharge planning needs with appropriate internal and external entities.
- Research and resolve issues related to benefits, member eligibility, non-elective and non-authorized services, coordination of benefits, care coordination, etc.
- Develop and deliver targeted education for the provider community related to policies, procedures, benefits, etc.
- Communicates with providers and other parties to facilitate care/treatment.
- Identifies members for referral opportunities to integrate with other products, services, and/or programs Identifies opportunities to promote quality effectiveness of healthcare services and benefit utilization.
- Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function.
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.
- Certification in Case Management may be preferred based upon designated department assignment.
- Continuous learning, as defined by the Company’s learning philosophy, is required.
- Certification or progress toward certification is highly preferred and encouraged.
- 2+ years of acute clinical experience as RN required.
- One (1) year of health insurance plan experience or managed care environment preferred.
- 1+ years Behavioral Health clinical experience 1+ years Managed Care of Utilization Management experience.
- 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:** $51,000-$77,000
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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