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Utilization Review RN

UST HealthProof

United States

Remote

USD 65,000 - 85,000

Full time

4 days ago

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Job summary

UST HealthProof seeks a dedicated Utilization Review RN to perform reviews for medical necessity across healthcare services. The role includes analyzing clinical requests, conducting retroactive reviews, and ensuring compliance with regulations. Ideal candidates will demonstrate clinical experience and possess a collaborative spirit to enhance patient care in a dynamic remote environment.

Benefits

401(k) Retirement Plan with employer matching

Medical, dental, and vision insurance

Paid vacation and sick leave

Quarterly incentive-based bonuses

Qualifications

Registered Nurse with current unrestricted license required.
Minimum of 2 years’ clinical experience including utilization review.
Demonstrated clinical knowledge and experience with healthcare delivery processes.

Responsibilities

Perform prospective, concurrent and retrospective review of medical services.
Analyze care patterns and resolve issues related to member benefits.
Establish discharge planning needs and recommend alternative services.

Skills

Healthcare

Medical Management

Business Process

Education

Bachelor’s degree in a related field

Registered Nurse license

Certification in Case Management

Tools

Microsoft Office Suite

Join to apply for the Utilization Review RN role at UST HealthProof

Who We Are

UST HealthProof is a trusted partner for health plans, offering an integrated ecosystem for health plan operations. Our BPaaS solutions manage complex admin tasks, allowing our customers to prioritize members’ well-being. With our commitment to simplicity, honesty, and leadership, we navigate challenges with our customers to achieve affordable health care for all.

Role Description

Utilization Review RN

Lead II – BPM

Who We Are

UST HealthProof is a trusted partner for health plans, offering an integrated ecosystem for health plan operations. Our BPaaS solutions manage complex admin tasks, allowing our customers to prioritize members’ well-being. With our commitment to simplicity, honesty, and leadership, we navigate challenges with our customers to achieve affordable health care for all.

We have a strong global presence and a dedicated workforce of over 4000 people spread across the world.

Our brand is built on the strong foundation of simplicity, integrity, people-centricity, and leadership. We stay inspired in our goal to unburden healthcare and ensure it reaches all, equitably and effectively.

You Are

UST HealthProof is searching for a highly motivated Utilization Review RN to join our team. As a Utilization Review RN, you will perform prospective, concurrent and retrospective review of inpatient, outpatient, ambulatory and ancillary services to ensure medical necessity, appropriate length of stay, intensity of service and level of care, including appeal requests initiated by providers, facilities and members.

The Opportunity

Review, research and authorize requests for authorization of elective, direct, ancillary, urgent, emergency, etc. services. Contact appropriate medical and support personnel to identify and recommend alternative treatment, service levels, length of stays, etc. using approved clinical protocols.
Analyze, research, respond to and prepare documentation related to retrospective review requests and appeals in accordance with local, state and federal regulatory and designated accreditation (e.g. NCQA) standards.
Establish, coordinate, and communicate discharge planning needs with appropriate internal and external entities.
Analyze patterns of care associated with disease progression; identify contractual services and organize delivery through appropriate channels.
Research and resolve issues related to benefits, member eligibility, non-elective and non-authorized services, coordination of benefits, care coordination, etc.
Identify and document quality of care issues; resolve or route to appropriate area for resolution.
Follow out-of-area/out-of-network services and make recommendations on patient transfer to in-network services and/or alternative plans of care.
Develop and deliver targeted education for provider community related to policies, procedures, benefits, etc.
As needed and in conjunction with Provider Services, may identify and negotiate reimbursement rates for non-contracted providers for services.

This position description identifies the responsibilities and tasks typically associated with the performance of the position. Other relevant essential functions may be required.

What You Need

Bachelor’s degree in a related field.

Registered Nurse with current unrestricted Registered Nurse license required.
Certification in Case Management may be preferred based upon designated department assignment. Certification or progress toward certification is highly preferred and encouraged.
Minimum of 2 years’ clinical experience which may include acute patient care, discharge planning, case management, and utilization review, etc.
Demonstrated clinical knowledge and experience relative to patient care and health care delivery processes.
Minimum 1 year health insurance plan experience or managed care environment preferred.
Skills & Competencies:
Excellent written and verbal communication skills. Excellent customer service and interpersonal skills.
Working knowledge of current industry Microsoft Office Suite PC applications.
Ability to apply clinical criteria/guidelines for medical necessity, setting/level of care and concurrent patient management.
Knowledge of current standard medical procedures/practices and their application as well as current trends and developments in medicine and nursing, alternative care settings and levels of service.
Knowledge of policies and procedures, member benefits and community resources.
Knowledge of applicable accreditation standards, local, state and federal regulations.
Other related skills and/or abilities may be required to perform this job based upon designated department assignment.

Compensation can differ depending on factors including but not limited to the specific office location, role, skill set, education, and level of experience. UST HealthProof provides a reasonable range of compensation for roles that may be hired in various U.S. markets as set forth below.

Role Location: Remote

Compensation Range: $65,000-$85,000

Benefits

Full-time, regular employees accrue up to 16 days of paid vacation per year, receive 6 days of paid sick leave each year (pro-rated for new hires throughout the year), 10 paid holidays, and are eligible for paid bereavement leave. They are eligible to participate in the Company’s 401(k) Retirement Plan with employer matching. They and their dependents residing in the US are eligible for medical, dental, and vision insurance, as well as the following Company-paid benefits: basic life insurance, accidental death and disability insurance, and short- and long-term disability benefits. Regular employees may purchase additional voluntary short-term disability benefits, and participate in a Health Savings Account (HSA) as well as a Flexible Spending Account (FSA) for healthcare, dependent child care, and/or commuting expenses. Certain regular employees may have the potential for quarterly incentive-based bonuses and or commissions depending on role. Benefits offerings vary in Puerto Rico.

Part-time employees receive 6 days of paid sick leave each year (pro-rated for new hires throughout the year) and are eligible to participate in the Company’s 401(k) Retirement Plan with employer matching.

Full-time temporary employees receive 6 days of paid sick leave each year (pro-rated for new hires throughout the year) and are eligible to participate in the Company’s 401(k) program with employer matching. They and their dependents residing in the US are eligible for medical, dental, and vision insurance.

Part-time temporary employees receive 6 days of paid sick leave each year (pro-rated for new hires throughout the year).

All US employees who work in a state or locality with more generous paid sick leave benefits than specified here will receive the benefit of those sick leave laws.

What We Believe

At UST HealthProof, we envision a bold future for American healthcare. Our values are the bedrock beliefs our organization holds dear. They not only define what our brand stands for but also serve as a compass guiding every action and decision.

Guiding Principles

These principles illuminate the path of ‘how’ we operate. They detail actions and behaviors we much embody to honor our values and achieve our goals.

Simplicity

Simplifying complexity underlines everything we do—this approach is what makes us unique. We come with an open mind and straightforward approach, cutting our way to the core with measurable and actionable insights.

Integrity

Integrity is our currency to build relationships. We believe in being open and honest. It is only natural when we have nothing to hide. It demonstrates that we are here to do the right thing, no matter who is watching.

People-Centricity

Everything that we do reflects our deep bonds with peers and customers. These aren't mere transactions, but transformational ties. They shape our culture and decisions, affirming that our true value lies in the lives we touch and impact.

Leadership

Taking ownership is about taking initiative, being in-charge and driving things to completion. It’s a brave choice to ‘own’ all aspects of our work, ensuring we take full responsibility for everything we handle.

Mission

A future possible only when health plans are free from administrative burdens so they can truly focus on what matters more – their members’ well-being.

Equal Employment Opportunity Statement

UST HealthProof is an Equal Opportunity Employer.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other applicable characteristics protected by law. We will consider qualified applicants with arrest or conviction records in accordance with state and local laws and “fair chance” ordinances.

UST HealthProof reserves the right to periodically redefine your roles and responsibilities based on the requirements of the organization and/or your performance.

#Healthproof

#CB

Skills

Healthcare,Medical Management,Business Process

Seniority level

Seniority level
Entry level

Employment type

Employment type
Full-time

Job function

Job function
Health Care Provider
Industries
IT Services and IT Consulting

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