Utilization Management Nurse

This is a fully remote position, open to applicants in United States.

📋 Description

• Comply with PACE program service authorization guidelines, ensuring participant care and claims are appropriate, necessary, medically justified, and align with care plans and PCP coordination decisions.

• Perform concurrent assessments of hospital admissions, which include both observation and inpatient stays.

• Facilitate timely transitions of care and retrospectively evaluate inpatient admissions lasting under 48 hours.

• Examine claims that are submitted in a manner inconsistent with service authorization.

• Conduct concurrent evaluations of subacute and SNF admissions, assisting in discharge planning and transitions of care.

• Coordinate and assess services provided by contracted providers to ensure alignment with authorizations, care plans, and PCP decisions.

• Leverage clinical expertise, critical thinking, and analytical skills to advocate for high-quality care, enhanced quality of life, and reduced hospitalizations when suitable.

• Keep precise records of patient-related interactions.

• Oversee the provider appeals process for denied claims.

• Evaluate provider network appeals and collaborate with the PACE Medical Director to provide written determinations.

⛳️ Requirements

• 3 to 5 years of experience in utilization management.

• Valid RN license.

• Demonstrated experience in risk-based integrated care models.

• Ability to utilize data to inform decisions and work collaboratively with both internal and external stakeholders.

• Strong strategic thinking, problem-solving, and decision-making capabilities.

• Exceptional communication and leadership skills.

• Position must be located in the United States.

• Visa sponsorship is not available for this position.

🏝️ Benefits

• Competitive salary and equity package.

• Comprehensive health, dental, and vision insurance.

• A collaborative, inclusive, and dynamic work environment.

• Opportunities for professional growth and development.