Utilization Management Nurse

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

📋 Description

• Supervise and manage the Utilization Management process to guarantee suitable, necessary, and cost-efficient healthcare delivery.

• Perform timely prospective, concurrent, and retrospective Utilization Management evaluations.

• Utilize summary plan documents and additional resources for utilization requests.

• Collaborate with relevant parties to apply the appropriate Utilization Management criteria within specified timelines.

• Advocate for quality care and cost-efficient outcomes for plan participants.

• Ensure adherence to CMS, URAC, and other regulatory standards and guidelines.

• Detect and report potential overutilization, underutilization, or inappropriate utilization.

• Identify potential catastrophic, high-risk, and disease management cases, referring them to the suitable team.

• Convey Utilization Management decisions and recommendations to providers and plan participants.

• Keep comprehensive, accurate, and confidential Utilization Management records.

• Engage in ongoing Utilization Management education and training.

• Uphold confidentiality in line with HIPAA regulations.

• Ensure continuity of inpatient care through early discharge planning.

• Identify and relay potential quality-of-care and patient-safety concerns to the Quality Improvement Coordinator.

• Execute other assigned duties.

⛳️ Requirements

• Minimum of 3 years of clinical nursing experience.

• Active and unrestricted RN license in the state of residency.

• Capability to thrive in a fast-paced, detail-oriented, and deadline-focused environment.

• Ability to maintain strict confidentiality and manage sensitive information with care.

• Experience in working independently.

• Strong problem-solving abilities and organizational skills.

• Excellent relationship-building skills and effective communication style.

• Certification in Utilization Management or Case Management is advantageous.

• Quiet workspace that is free from distractions.

• Reliable internet connection.

• Compliance with company security protocols, including VPNs, secure passwords, and authorized devices/software.

• Must be based in the US.

• Availability to work Monday through Friday during standard business hours according to the relevant time zone.

• Adherence to HIPAA and company policies.

🏝️ Benefits

• Competitive compensation based on experience and performance.

• Comprehensive benefits package with generous employer contributions.

• Flexible and remote working arrangements.

• 401k plan with favorable employer match and immediate vesting.

• Opportunities for personal and professional development.

• Supportive family benefits, including paid leave for new family members.

• Company-wide philanthropic initiative, Valenz Communities Connection.

• Provision of necessary equipment.

• Generous subsidy for company-sponsored Medical, Dental, and Vision insurance.

• Access to services via Healthcare Blue Book and KISx Card.

• Options for HSA, FSA, and DCFSA spending accounts.

• Flexible working conditions.

• Generous Paid Time Off, encompassing vacation, sick leave, and paid holidays.

• Employee Assistance Program featuring professional counseling, referrals, and additional services.

• Paid maternity and paternity leave.

• Pet insurance available.

• Employee discounts on mobile plans, car rentals, and computers.

• Opportunities for community engagement, including paid time off for philanthropic activities.