Utilization Management Nurse

Softechub; United States; Presencial; USD 70.000 - 100.000; Tempo integral

Resumo da vaga

Softechub is seeking a qualified professional to oversee utilization management, prior authorization, and payer claims reviews. You will author high-difficulty clinical tasks, synthesize chart data, and ensure clinical accuracy and safety across care settings.

The role emphasizes cross-functional collaboration with physicians, nurses, therapists, and payers, plus calibration of evaluation rubrics and content improvement. A healthcare license and relevant experience are required.

Qualificações

• Bachelor’s or graduate degree in a healthcare field, or equivalent practical experience.
• Active professional license or board certification where applicable.
• Experience in clinical practice, healthcare operations, medical review, AI evaluation, or related analytics preferred.
• Experience reviewing expert work, creating clinical education content, or quality-improvement programs advantageous.

Responsabilidades

• Develop high-difficulty clinical tasks, long-chart scenarios, and gold-standard answers with evaluation criteria.
• Evaluate fragmented records to identify trends, risks, and required actions.
• Assess outputs for clinical accuracy, practicality, and patient safety across care settings.
• Apply rubrics to measure clinical reasoning, terminology, documentation quality, regulatory alignment, and payer accuracy.
• Review tasks across mobility, discharge planning, nutrition, diabetes, psychosocial safety, and denials where applicable.
• Calibrate and review peers to ensure consistent quality and address rubric inconsistencies.
• Coordinate with physicians, nurses, therapists, pharmacists, social workers, coders, payers, and others for cross-functional reviews.
• Incorporate calibration feedback and revise content to align with project standards.

Conhecimentos

Clinical evaluation

Regulatory compliance

Medical documentation

Quality assurance

Formação

Bachelor's degree in healthcare or related field

Descrição da vaga

Utilization Management, Prior Authorization, and Payer Claims. 3 years of experience. Licence: RN or equivalent.

Duties

• Clinical Benchmark Authoring & Task Design: Develop high-difficulty clinical tasks, long-chart scenarios, realistic workplace cases, gold-standard answers, and evaluation criteria within the assigned discipline
• Longitudinal Chart Synthesis: Evaluate fragmented, multi-encounter records and identify clinically meaningful trends, contradictions, omissions, risks, and required actions
• Clinical Accuracy & Safety Review: Assess whether outputs are clinically accurate, practical, evidence-aligned, patient-safe, and appropriate for the relevant care setting
• Rubric Application & Scoring: Apply evaluation criteria defined by the Functional SME Lead to assess outputs for clinical reasoning, terminology, documentation quality, regulatory alignment, payer accuracy, and patient-safety implications
• Specialty Task Evaluation: Depending on the assigned area, review tasks involving mobility and discharge planning, swallow and diet-texture recommendations, medical necessity, prior authorization, claims and denials, nutrition support, diabetes management, psychosocial safety, infection…
• Peer Review & Calibration - Senior Track: Review and calibrate pod members’ work, resolve edge-case ambiguities, identify rubric inconsistencies, and maintain day-to-day quality standards
• Cross-Functional Review: Evaluate tasks that require coordination across physicians, nurses, therapists, pharmacists, social workers, dietitians, coders, case managers, payers, laboratory professionals, or emergency personnel
• Iterative Refinement: Incorporate calibration feedback, revise task content and solutions, and participate in multiple critique cycles to align deliverables with project standards
• Escalation & Quality Ownership - Senior Track: Escalate genuine clinical, regulatory, or rubric ambiguities to the Functional SME Lead and support consistent decision-making across the pod
• Bachelor’s degree, graduate degree, professional degree, or equivalent practical experience in a relevant healthcare discipline
• Active professional license, board certification, or recognized industry credential where applicable
• Experience in clinical practice, healthcare operations, medical review, AI evaluation, data annotation, content review, quality assurance, clinical documentation, or a related analytical role is preferred
• Prior experience reviewing expert work, creating clinical education content, developing assessment materials, or participating in quality-improvement programs is advantageous

Required experience

• 3 years of experience
• Active PT, OT, SLP, RN, RD/RDN, LCSW, PharmD, MD, DO, or other applicable professional license.
• Licence: RN or equivalent

12 weeks

Hours

Full-time or Part time. 40h or 20h per week with 4 hours PST overlap.

Time-zone overlap

4 hours PST overlap

United States