Utilization Review Nurse

Job Description:

The Utilization Review Nurses role is to ensure that health care services are administered with quality, cost efficiency, and within compliance. By continuously reviewing and auditing member treatment records, the utilization review nurse will ensure members do not receive unnecessary procedures, ineffective treatment, or experience unnecessarily extensive hospital stays.

Responsibilities:

Some of the major role components include:

• Concurrent review of members clinical information for efficiency

• Ongoing review of preauthorization requests for medical necessity

• Coordinate member discharge planning needs as part of an integrated care team

• Employ effective use of knowledge, critical thinking, and skills to:

• Advocate quality care and enhanced quality of life

• Prevent member complications during hospital stay.

• Advocate for decreased hospital stay when appropriate.

• Actively participate in discharge planning processes, engaging assigned Case Manager for MLTC and SNP members as well as the members care team to ensure timely discharge, appropriate follow-up, and continuity of care.

• Facilitate requests for Sub-Acute care, DME, Home Health Care and Transportation for members.

• Refer cases with quality-of-care concerns to the CMO and Quality Department

Qualifications:

• Strong interpersonal and communication skills and the ability to work effectively with a wide range of constituencies in a diverse community.

• Ability to plan, implement, and evaluate individual member care programs.

• Knowledge of medical billing procedures.

• Intermediate skills in Microsoft office suite and google.

• Ability to manage a large workload and thrive in a results-driven, fast-paced environment.

• Experience with Medicare Managed Care utilization management and applicable regulations.

• Commitment to maintain working knowledge and compliance with departmental policies & procedures, CMS requirements, NCQA, AAHC, as well as Federal & State guidelines, as applicable.

• Ability to practice ethics in daily operations, demonstrating professionalism and commitment to success, inspiring others towards high-level of engagement and teamwork.

• State licensure as a Practical Nurse (LPN) in good standing.

• Minimum 1-year prior experience completing utilization reviews for an HMO.

Working Conditions:

• No or very limited physical effort require.

• Work environment involves minimal exposure to physical risks, such as operating dangerous equipment or working with chemicals.

• Our company utilizes a hybrid work model that is based upon position requirements, performance, productivity, and company needs and may be modified or changed at any time.

Equal Employment Opportunity

Sonder Health Plans is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.

Sponsorship in US

Must be eligible to work in the U.S. without Sponsorship.