Utilization Management Nurse- Part-Time – REMOTE

Rxadvance Corporation; Southborough (MA); Remote; USD 34,000 - 55,000; Part time

Job summary

nirvanaHealth, operating under RxAdvance Corp., is seeking a Utilization Management Nurse for a part-time remote role. The position focuses on prospective, concurrent, and retrospective medical necessity reviews and care coordination to ensure quality, cost-effective healthcare services in compliance with standards.

The role requires an active RN license and 0–2 years of UM or case management experience, with Medicare/Medicaid knowledge being a plus.

Qualifications

• Associate’s degree in nursing required.
• Bachelor’s degree in nursing preferred.
• Active RN license required.
• 0–2 years in utilization management or case management preferred.
• Knowledge of Medicare/Medicaid, HMO and private insurance preferred.

Responsibilities

• Performs prospective, concurrent, and retrospective medical necessity reviews for healthcare products and services using clinical criteria or evidence-based guidelines.
• Performs level of care determinations and monitors length of stay based on illness severity and service intensity.
• Conducts initial clinical review per accreditation, laws, and regulations.
• Ensures timeliness of medical necessity reviews per guidelines.
• Verifies accuracy of codes and services with proper documentation.
• Coordinates discharge planning and transition of care with RN case managers and healthcare team.

Skills

Clinical judgement

Nursing license

Communication

Team collaboration

Education

Associate’s degree in nursing

Bachelor’s degree in nursing

Tools

MS Word

Excel

Access

PowerPoint

Job description

Company Overview:

Join us in our mission to transform healthcare! nirvanaHealth (under RxAdvance Corp.) is committed to bringing the art of the possible to the payer and PBM industries. We invest in our employees at every stage of life. Success radiates across all levels of our organization, driven by competitive benefits and a strong focus on employee wellness, we aim to support all aspects of employee growth.

Characterized by curiosity, innovation, and an entrepreneurial mindset, nirvanaHealth is the first to offer medical and pharmacy benefit management solutions that run on the same platform, made possible by our creation, Aria — the first robotic process automation cloud platform designed for healthcare.

Under the leadership of our Chairman John Sculley, former Apple CEO, and our President & CEO Ravi Ika, nirvanaHealth endeavors to sizably reduce the $1 trillion in waste in healthcare administrative and medical costs. We are seeking self-determined players to join our team — folks who embrace the grind and hustle of a growing company, are collaborative and innovative, are life-long learners and growers, and have an entrepreneurial and positive mindset.

Job Summary:

The Utilization Management (UM) Nurse will have well-developed knowledge and skills in utilization management, medical necessity, and care coordination. This individual is responsible for performing a variety of prospective, concurrent, and retrospective UM-related activities. The UM nurse’s role is to ensure that healthcare services are administered with quality, cost efficiency, and within compliance and regulation standards. The UM Nurse is also responsible for participating in initial clinical review.

NOTE: This is a Part-Time REMOTE position for 4 Hours on Friday Evening and 4 Hours each on Saturday and Sunday. Estimated 12 Hours/ Week.

Job Responsibilities (but not limited to):

• Performs prospective, concurrent, and retrospective medical necessity reviews for healthcare products and services utilizing appropriate clinical criteria and/or evidence-based guidelines.
• Performs level of care (LOC) determinations and monitors length of staybased on severity of illness and intensity of service using the appropriate clinical criteria.
• Conducts initial clinical review (in accordance with accreditation, laws, and regulations).
• Ensures regulatory and/or accreditation guidelines are met for timeliness of medical necessity reviews.
• Verifies accuracy of codes and services and applies them accurately with appropriate documentation.
• Coordinates discharge planning needs and transition of carewith the registered nurse case managers and other healthcare team members, as deemed appropriate.
• Communicates member, provider, and facility notifications, citing clinical criteria and Medical Director denial rationale, when indicated.
• Collaborates with a multi-disciplinary staff and interdepartmentally.
• Establishes and maintains professional relationships with providers and facilities to establish a smooth operational flow of authorizations and referrals.
• Evaluates, coordinates, manages, and documents all UM-related activities.
• Maintains a current knowledge of medical necessity criteria and UM-related policies and procedures.
• Assists in the development and maintenance of medical necessity criteria and clinical pathways.
• Participates in the monitoring of the effectiveness and outcomes of the UM program.
• Participates in UM program process improvement initiatives.
• Complies with all regulatory and accreditation standards related to utilization management and/or case management.’
• Complies with Utilization Management and Case Management standards of practice.
• Performs other duties as assigned

Qualifications:

Education and/or Training:

Associate’s degree in nursing required

• Bachelor’s degree in nursing preferred

Professional Experience:

• 0- 2 years of prior experience in utilization management or case management is preferred.
• Knowledge of Medicare is preferred.
• Knowledge of Medicaid, HMO, and private insurance is preferred.
• Knowledge in accreditation standards (i.e., NCQA, URAC) is preferred.

Licenses/Certifications:

• Current active, unrestricted state licensure as a Registered Nurse is required.
• Utilization Management or Case Management certification is preferred.

Specialized Skills & Technical Skills:

• Professional license must be with a scope of practice that will be relevant to initial clinical review.
• Strong clinical background and solid clinical judgement to conduct initial clinical review is required.
• Strong PC skills; MS Word, Excel, Access, and PowerPoint.

Additional Considerations:

• Applicants must be able to pass a background investigation as all offers are pending a successful completion of background check per the company policy.