Job Description
At our organization, we are dedicated to improving healthcare affordability for patients and enhancing the practice of medicine for providers. As a physician-led company, we streamline administrative tasks and leverage predictive analytics and AI to empower our partner physician practices in delivering high-quality healthcare focused on outcomes and value.
Position Overview:
Join us in reshaping healthcare for the better!
In this role, you will work alongside a team of independent and autonomous nurses, breaking down barriers to ensure quality and timely care.
Responsibilities:
Perform utilization review services in compliance with federal, state regulations, and industry standards.
Gather, analyze, and document clinical data within the documentation record.
Conduct timely reviews of healthcare services using appropriate medical criteria to make clinical determinations.
Communicate pre-certifications and review determinations to all stakeholders as required.
Collaborate with the Medical Director and Peer Reviewers on cases requiring medical review.
Interface with ordering providers and provider organizations, occasionally communicating with members or their representatives.
Initiate referrals of targeted patients into disease management programs to enhance continuity and quality of care.
Manage and document after-hours phone calls from members and providers on a rotational basis.
Maintain confidentiality of member information, case records, and file entries.
Participate in quality management activities and assist with clinical and client-specific reports.
Stay updated on regulatory requirements and integrate medical group guidelines and standards into daily duties.
Engage with the IT Department for technical support related to computer systems and data.
Requirements:
Active and unrestricted Registered Nurse license.
Minimum of five years of experience in various healthcare settings.
Knowledge of utilization review, managed care, and community health.
Proficiency in MS Word, Excel, and other relevant software.
Strong organizational, writing, and verbal communication skills.
Ability to prioritize and adapt to changing business needs.
Excellent clinical judgment, compassion, and a positive attitude.
Preferred Qualifications:
Advanced degree or certification in Case Management, Utilization Review, and/or Quality.
Interest in Informatics and knowledge of Population Health and Disparities.
Compensation:
Our comprehensive compensation package includes competitive base salary, medical, dental, and vision plans, long and short-term disability, life insurance, and a 401k plan with a generous match. We also offer paid holidays and flexible time off to ensure work-life balance.
Equal Opportunity Employer:
Diversity, inclusion, and belonging are fundamental to our values. We are committed to equal opportunity employment and making decisions without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, or any other protected status.
Security Commitment:
This role adheres to all security policies and procedures to safeguard PHI and intellectual properties.
Employment Type: Full-Time
Salary: $ 70,000.00 75,000.00 Per Year
Job Tags
Holiday work, Full time, Temporary work, Flexible hours,