Utilization Review Nurse

OptiRoi Media; Georgia (VT); On-site; USD 80,000 - 95,000; Full time

Job summary

Join a mission-driven company dedicated to transforming healthcare in the U.S. as a Utilization Review Nurse. In this pivotal role, you will evaluate the medical necessity of healthcare services, ensuring compliance with clinical guidelines while collaborating with healthcare providers. Your expertise will directly impact the quality of care for members, making healthcare more affordable and transparent. This is a unique opportunity to leverage your nursing skills in a dynamic environment focused on improving patient outcomes. If you're ready to make a meaningful difference, this role is for you!

Benefits

Competitive salary

Bonus opportunity

Equity package

Comprehensive Medical benefits

Dental benefits

Vision benefits

Paid vacation

Company holidays

Impactful work in healthcare transformation

Qualifications

• 5+ years of nursing experience, preferably in a hospital setting.
• Experience in medical billing and/or coding in provider or payor settings.

Responsibilities

• Evaluate medical necessity using Milliman Care Guidelines.
• Review medical records and assess healthcare service appropriateness.
• Collaborate with providers to gather additional information.

Skills

Critical Thinking

Written Communication

Problem Solving

Cross-functional Collaboration

Education

Registered Nurse (RN)

Tools

Microsoft Suite

Job description

Sidecar Health is redefining health insurance. Our mission is to make excellent healthcare affordable and attainable for everyone. We know that to accomplish this lofty mission, we need driven people who will make things happen.

The passionate people who make up Sidecar Health’s team come from all over, with backgrounds as tech leaders, policy makers, healthcare professionals, and beyond. And they all have one thing in common—the desire to fix a broken system and make it more personalized, affordable, and transparent.

If you want to use your talents to transform healthcare in the United States, come join us!

*Must reside in Florida, Georgia, Kentucky, or Ohio for consideration*

About the Role

As a Utilization Review Nurse, you'll be at the forefront of evaluating the medical necessity and quality of healthcare services for our members, guaranteeing adherence to established guidelines. You will also be responsible for reviewing upcoming services and good faith estimates for our members and writing letters based on the Sidecar Health policy.

What You'll Do

• Utilize Milliman Care Guidelines (MCG) to evaluate the medical necessity and appropriateness of proposed and ongoing treatments for our members.
• Participate in quality improvement initiatives to enhance the efficiency and effectiveness of the clinical review process.
• Ensure compliance with established clinical guidelines, policies, and regulatory requirements.
• Review and analyze medical records to assess the appropriateness and necessity of healthcare services.
• Evaluate good faith estimates and “prebills” to determine scheduled care, including highlighting care that may not be included in the estimate (labs, radiology, pre-op visits, etc).
• Collaborate with healthcare providers to gather additional information when needed.
• Draft letters to send to members outlining benefits and other considerations.
• Collaborate with provider team and Member care team to evaluate care shopping options.
• Review claims reconsiderations and appeals, providing expert guidance to ensure accurate processing and resolution of issues coverage determination.
• Assess claims for balance billing protections to ensure compliance with applicable regulations and internal policies.

What You'll Bring

• Clinical credentials (RN).
• 5+ years of experience as a nurse providing care to patients, preferably in a hospital setting.
• Medical billing and/or coding experience. This can be in a provider setting (billing, revenue cycle management, clinical auditing, legal compliance nurse) or payor setting (UM review, prior auth review, payment integrity, etc).
• Excellent written communication skills with experience drafting member, patient, and provider-facing letters.
• Ability to think critically and make decisions with limited information.
• Exceptional cross-functional collaboration skills with the ability to make recommendations to leadership.
• Ability to problem solve and handle escalated cases.
• Experience with Microsoft Suite.

What You'll Get

• Competitive salary, bonus opportunity, and equity package.
• Comprehensive Medical, Dental, and Vision benefits.
• Paid vacation and company holidays.
• Opportunity to make an impact at a rapidly growing mission-driven company transforming healthcare in the U.S.

Sidecar Health adopts a market-based approach to compensation, where base pay varies depending on location and is further influenced by job-related skills and experience. The current expected salary range for this position is $80,000 - $95,000.

Sidecar Health is an Equal Opportunity employer committed to building a diverse team. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status or disability status.