Utilization Management Nurse

Valenz•Phoenix, AZ

42d•Remote

About The Position

As a Utilization Management Nurse, you will have a meaningful impact each day by delivering comprehensive, patient centered care. You’ll assess individual needs, shape personalized care plans, and bring together the right healthcare partners to keep patients moving forward. With your clinical insight, you’ll help members navigate the healthcare system with confidence, reinforce treatment plans, and champion high quality outcomes through clear communication, education, and steady support. You’ll also play an important role in promoting wellness, using resources wisely, and ensuring we meet both regulatory and organizational standards. You’ll also have the chance to work on a wide variety of cases, which is a great way to build new skills, expand your clinical thinking, and grow your expertise over time.

Requirements

3+ years of clinical nursing experience.
1+ years of UM experience
Active, Unrestricted RN License in your state of residence.
Ability to work in a fast-paced, detailed, deadline-driven environment.
Ability to maintain strict confidentiality and handle sensitive information with discretion.
Experience working independently with strong problem solving and organization skills.
Strong aptitude for relationship building with a highly effective communication style.
You’ll need a quiet workspace that is free from distractions.
Reliable internet connection—if you can use streaming services, you’re good to go!
Adherence to company security protocols, including the use of VPNs, secure passwords, and company-approved devices/software.
You must be US based, in a location where you can work effectively and comply with company policies such as HIPAA.

Nice To Haves

Utilization Management or Case Management Certification.

Responsibilities

Review prospective, concurrent, and retrospective UM cases and apply the appropriate criteria and plan documents.
Work with providers and internal partners to make sure the right guidelines are used within the required timelines.
Support quality care and cost-effective outcomes that help members stay healthy and engaged.
Follow CMS, URAC, and other regulatory requirements tied to UM activities.
Flag any potential overuse, underuse, or misuse of services.
Identify high risk, catastrophic, or disease management cases and route them to the right teams.
Communicate UM decisions clearly with providers and members so everyone stays aligned.
Document UM activities accurately and maintain confidentiality at all times.
Participate in ongoing education to keep your UM knowledge fresh and current.
Help support smooth transitions of care for inpatient members, including early discharge planning.
Bring forward any potential quality or patient safety concerns.
Take on additional responsibilities as needed to support the team.
Reasonable accommodation may be made to enable individuals with disabilities to perform essential duties.

Benefits

Generously subsidized company-sponsored Medical, Dental, and Vision insurance, with access to services through our own products, Healthcare Blue Book and KISx Card.
Spending account options: HSA, FSA, and DCFSA
401K with company match and immediate vesting
Flexible working environment
Generous Paid Time Off to include vacation, sick leave, and paid holidays
Employee Assistance Program that includes professional counseling, referrals, and additional services
Paid maternity and paternity leave
Pet insurance
Employee discounts on phone plans, car rentals and computers
Community giveback opportunities, including paid time off for philanthropic endeavors