Utilization Review – RN

Job Description

Utilization Review – RN

Lead II – BPM

Who We Are

Advantasure is a growing company and a member of the UST HealthProof family, Advantasure champions innovative solutions with an eye on the future—providing health plans with the flexibility to adapt to a changing regulatory environment and evolving business needs. Leveraging the industry’s leading experts in government-sponsored health plans, Advantasure offers solutions for administrative cost management, quality patient outcomes and experiences, enrollment growth, risk adjustment and quality and provider engagement initiatives.

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**

The Utilization Review RN will perform 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 including member outreach assessments. **

The Opportunity**

• 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.
• Analyze 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, care coordination, etc.
• Identify and document the quality of care issues; resolve or route to the appropriate area for resolution.
• Follow out-of-area/out-of-network services and make recommendations on patient transfer to in-network services and/or alternative plans of care.
• Develop and deliver targeted education for the provider community related to policies, procedures, benefits, etc.

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**

• 2+ years of clinical experience with may include acute patient care, discharge planning, case management, utilization review, etc required
• 1 year of health insurance plan experience or managed care environment preferred
• Current unrestricted Registered Nurse license required
• Certification in Case Management preferred
• InterQual experience required
• Demonstrated clinical knowledge and experience relative to patient care and healthcare delivery processes.
• 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:** $60,000-$90,000

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

#Advantasure

#CB