Remote Utilization Management Nurse - Elevate Senior Care

Curana Health, Inc.; United States; Remote; USD 85,000 - 110,000; Full time

Job summary

Curana Health, Inc. is seeking a Utilization Management Nurse for a primarily remote telephonic role focused on review and prior authorizations, concurrent and retrospective care reviews, and transition planning across hospitals and skilled nursing facilities.

You will partner with Plan Medical Director and Care Management to ensure compliant, cost-effective care and identify opportunities to improve outcomes, cost savings, and care quality.

Qualifications

• Minimum 2 years clinical RN/LPN/LVN experience.
• Minimum 1 year managed care or health plan experience preferred.
• Experience in health plan utilization management, facility concurrent review discharge planning, and transfer coordination required.
• Medicare Advantage experience preferred.
• Experience with InterQual or MCG authorization criteria preferred.
• Excellent computer skills and ability to learn new systems.
• Strong attention to detail, organizational skills and interpersonal skills required.
• Demonstrated ability to problem solve and manage professional relationships.

Responsibilities

• Performs concurrent and retrospective reviews on facility and appropriate home health services.
• Monitors level and quality of care; supports discharge planning and transition planning for acutely and chronically ill patients.
• Determines observed vs acute inpatient status as part of the prior authorisation process.
• Engages with providers in proactive discharge/transition planning.
• Prepares CMS-compliant notification letters for NON-certified and negotiated days.
• Maintains accurate records of all communications.
• Monitors utilization reports to ensure compliance with reporting and turnaround times.
• Coordinates cost-saving opportunities and quality improvement across the continuum.

Skills

Clinical experience

Managed care experience

Medicare Advantage experience

InterQual/MCG criteria

Computer skills

Attention to detail

Interpersonal skills

Problem solving

Education

Nursing license

Tools

EMR systems

Job description

Curana Health, Inc. is seeking a Utilization Management Nurse for a primarily remote telephonic role focused on review and prior authorizations, concurrent and retrospective care reviews, and transition planning across hospitals and skilled nursing facilities.

You will partner with Plan Medical Director and Care Management to ensure compliant, cost-effective care and identify opportunities to improve outcomes, cost savings, and care quality.