Utilization Management Nurse- Part-Time - REMOTE

Rxadvance Corporation•Southborough, MA

53d•Remote

About The Position

Join nirvanaHealth (under RxAdvance Corp.) in our mission to transform healthcare by bringing the art of the possible to the payer and PBM industries. We invest in our employees at every stage of life, offering competitive benefits and a strong focus on employee wellness to support all aspects of employee growth. nirvanaHealth is characterized by curiosity, innovation, and an entrepreneurial mindset. We are the first to offer medical and pharmacy benefit management solutions that run on the same platform, made possible by our creation, Aria – the first robotic process automation cloud platform designed for healthcare. Under the leadership of our Chairman John Sculley, former Apple CEO, and our President & CEO Ravi Ika, nirvanaHealth endeavors to sizably reduce the $1 trillion in waste in healthcare administrative and medical costs. We are seeking self-determined players to join our team – folks who embrace the grind and hustle of a growing company, are collaborative and innovative, are life-long learners and growers, and have an entrepreneurial and positive mindset. This is a Part-Time Remote position requiring 4 hours on Friday evening and 4 hours each on Saturday and Sunday, totaling an estimated 12 hours per week.

Requirements

Associate's degree in nursing required
Current active, unrestricted state licensure as a Registered Nurse is required.
Strong clinical background and solid clinical judgement to conduct initial clinical review is required.
Strong PC skills; MS Word, Excel, Access, and PowerPoint.

Nice To Haves

Bachelor’s degree in nursing preferred
0- 2 years of prior experience in utilization management or case management is preferred.
Knowledge of Medicare is preferred.
Knowledge of Medicaid, HMO, and private insurance is preferred.
Knowledge in accreditation standards (i.e., NCQA, URAC) is preferred.
Utilization Management or Case Management certification is preferred.
Professional license must be with a scope of practice that will be relevant to initial clinical review.

Responsibilities

Performs prospective, concurrent, and retrospective medical necessity reviews for healthcare products and services utilizing appropriate clinical criteria and/or evidence-based guidelines.
Performs level of care (LOC) determinations and monitors length of stay based on severity of illness and intensity of service using the appropriate clinical criteria.
Conducts initial clinical review (in accordance with accreditation, laws, and regulations).
Ensures regulatory and/or accreditation guidelines are met for timeliness of medical necessity reviews.
Verifies accuracy of codes and services and applies them accurately with appropriate documentation.
Coordinates discharge planning needs and transition of care with the registered nurse case managers and other healthcare team members, as deemed appropriate.
Communicates member, provider, and facility notifications, citing clinical criteria and Medical Director denial rationale, when indicated.
Collaborates with a multi-disciplinary staff and interdepartmentally.
Establishes and maintains professional relationships with providers and facilities to establish a smooth operational flow of authorizations and referrals.
Evaluates, coordinates, manages, and documents all UM-related activities.
Maintains a current knowledge of medical necessity criteria and UM-related policies and procedures.
Assists in the development and maintenance of medical necessity criteria and clinical pathways.
Participates in the monitoring of the effectiveness and outcomes of the UM program.
Participates in UM program process improvement initiatives.
Complies with all regulatory and accreditation standards related to utilization management and/or case management.
Complies with Utilization Management and Case Management standards of practice.
Performs other duties as assigned.