Utilization Management Nurse

Valenz • Phoenix, AZ

3d • Remote

About The Position

As a Utilization Management Nurse, you’ll oversee and manage the Utilization Management process to ensure the appropriate, necessary, and cost-effective delivery of healthcare services to plan participants. You will review UM activities, including prospective, concurrent, and retrospective reviews, and collaborate with our internal teams and healthcare professionals to ensure the delivery of high-quality care while minimizing unnecessary healthcare expenses.

Requirements

• 3+ years of clinical nursing 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.
• 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.

Nice To Haves

• Utilization Management or Case Management Certification.

Responsibilities

• Conduct timely reviews of UM activities, including prospective, concurrent, and retrospective reviews and apply to summary plan documents or other resources related to the request.
• Collaborate with appropriate parties to apply the correct UM criteria within the appropriate timelines.
• Promote quality care and cost-effective outcomes that enhance the physical, psychosocial, and vacation health of plan participants.
• Ensure compliance with regulatory standards and guidelines related to UM activities, such as those set forth by CMS, URAC, and other regulatory agencies.
• Identify and report cases of potential overutilization, underutilization, or improper utilization of healthcare services.
• Identify potential catastrophic, high-risk, and disease management cases and refer cases to the appropriate team.
• Communicate UM decisions and recommendations to healthcare providers and plan participants.
• Maintain accurate and complete records of UM activities and ensure confidentiality of sensitive information.
• Participate in ongoing UM education and training to stay up-to-date with industry developments.
• Maintain a high level of confidentiality in accordance with HIPAA.
• Maintain an active role in assuring continuity of care for all inpatients through early discharge planning.
• Identify and communicate to the Quality Improvement Coordinator potential quality of care and patient safety issues.
• Perform other duties as assigned

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

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed