Utilization Management Nurse- Part-Time - REMOTE

nirvanaHealth, LLC; Southborough (MA); Remote; USD 52,000 - 55,000; Part time

Job summary

nirvanaHealth, LLC in Southborough, MA is seeking a Utilization Management (UM) Nurse for a part-time remote role. The position totals 12 hours per week across Friday evening and Saturday/Sunday shifts.

The UM Nurse performs prospective, concurrent, and retrospective medical necessity reviews, makes level of care determinations, and ensures regulatory compliance. An RN license is required; Medicare/Medicaid knowledge is preferred.

Qualifications

• Associate's degree in nursing required.
• Bachelor's degree in nursing preferred.
• 0-2 years in UM or case management preferred.
• Medicare knowledge preferred.
• Medicaid/HMO/private insurance knowledge preferred.
• NCQA/URAC accreditation knowledge preferred.

Responsibilities

• Performs prospective, concurrent, and retrospective medical necessity reviews.
• Performs level of care determinations and monitors length of stay.
• Conducts initial clinical review in accordance with laws and regulations.
• Ensures timeliness of medical necessity reviews per guidelines.
• Verifies accuracy of codes and services with documentation.
• Coordinates discharge planning with registered nurse case managers and team.
• Communicates criteria and rationale to members, providers, and facilities.
• Collaborates with multidisciplinary staff to ensure smooth authorizations and referrals.
• Maintains knowledge of medical necessity criteria and UM policies.

Skills

Clinical judgement

Regulatory compliance

Education

Associate's degree in nursing

Bachelor's degree in nursing

Tools

MS Word

Excel

Access

PowerPoint

Job description

If you are unable to complete this application due to a disability, contact this employer to ask for an accommodation or an alternative application process.

Part Time Southborough, MA, US

Salary Range: $38.00 To $40.00 Hourly

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.