Job Description
We are dedicated to enhancing healthcare affordability for patients and restoring the fulfillment of practicing medicine for providers. As a physician-led organization, 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.
Driven by empathy, we enable physicians to anticipate patient needs, strengthen patient-physician connections through virtual, and use AI to proactively prevent avoidable health events. This approach increases patient and practice engagement, making a significant positive impact on patient outcomes.
Join us as we lead healthcare towards a brighter future!
Job Title: Utilization Review Nurse
Location: Remote
What You'll Be Doing:
Conducting utilization review services in accordance with federal, state regulations, and URAC standards for client members seeking healthcare treatment and services.
Collecting, analyzing, and documenting clinical data within the documentation record.
Timely review of healthcare services using appropriate medical criteria to make clinical determinations.
Communicating pre-certifications and review determinations to all parties involved, complying with regulations, URAC standards, and organizational policies.
Collaborating with Medical Directors and Peer Reviewers on cases requiring review of medical necessity, treatment appropriateness, and quality of care.
Liaising with ordering providers and provider organizations regularly, occasionally communicating with members or their representatives.
Initiating referrals for targeted patients into disease management programs to enhance continuity and quality of care.
Managing after-hours phone calls from members and providers on a rotational basis.
Ensuring confidentiality of member information, case records, and file entries.
Participating in quality management activities.
Facilitating client-specific benefit exhaustion letters upon request.
Assisting in the development of clinical and client-specific reports and materials for committee meetings.
Maintaining current knowledge of regulatory requirements across multiple jurisdictions and medical groups.
Integrating knowledge of medical group guidelines and URAC standards into daily duties.
Continuing professional growth and education in line with the Illinois Nurse Practice Act.
Interacting with the IT Department for technical support related to computer systems.
What You'll Need to Have:
Active and unrestricted Registered Nurse license.
Five years of experience in various healthcare settings.
Proficiency in utilization review, managed care, and community health.
Strong computer skills including MS Word, Excel, and MS Access.
Excellent organizational, writing, and verbal communication skills.
Ability to prioritize tasks and adapt to changing business needs.
Outstanding clinical judgment, compassion, and a positive attitude.
Would Love for You to Have:
Advanced degree or certification in Case Management, Utilization Review, and/or Quality.
Interest or experience in Informatics.
Knowledge of Population Health and Disparities.
Compensation:
Offers a comprehensive compensation package beyond base salary, including medical, dental, and vision plans, long and short-term disability, life insurance, and a generous 401k match. Our paid time off program includes holidays and flexible time to balance work demands and personal needs.
The base pay range for this role is between $70,000.00 to $75,000.00 per year, paid bi-weekly, with final compensation decisions based on factors like skill set, experience, education, location, and certifications.
Our Commitment to Equal Opportunity Employment:
Diversity, inclusion, and belonging are fundamental values. We are an equal opportunity employer committed to making employment decisions without regard to race, religion, color, age, sex, sexual orientation, gender identity, national origin, citizenship, marital status, disability, veteran status, pregnancy, or any other protected status under federal, state, and local laws.
Security Responsibilities:
This position adheres to all security policies and procedures to protect PHI and Intellectual Properties, with specific responsibilities defined by the hiring manager for security-specific roles.
Employment Type: Full-Time
Salary: $ 70,000.00 75,000.00 Per Year
Job Tags
Weekly pay, Holiday work, Full time, Temporary work, Local area, Flexible hours,