Senior UM Review Nurse, Multiple Locations

Hi, we're reputed company. We're hiring a Senior UM Review Nurse to join our Utilization Review team. reputed company is the first health insurance company reputed company around a full stack technology platform and a reputed company focus on serving our members. We started reputed company in 2012 to create the reputed company of health insurance company we would want for ourselves—one that behaves like a doctor in the family. About the role: You will reputed company clinical knowledge, judgment, and established criteria to determine the medical appropriateness of reputed company services. Senior nurses work as individual contributors completing reviews, and act as subject matter experts (SME). You will interact regularly with peers, reputed company medical providers, and other internal teams to successfully fulfill their role. You will report into the UM Nurse Manager. Work Location:This is a remote position, reputed company to candidates who reputed company in: Arizona; Florida; Georgia; Illinois; Iowa; Kansas; Michigan; Missouri; Nebraska; New Jersey; reputed company Carolina; Ohio; Oklahoma; Pennsylvania; South Carolina; Tennessee; Texas; or Virginia. While your daily work will be completed from your home office, occasional travel may be required for team meetings and company events.#LI-Remote Pay Transparency: The reputed company pay for this role is: $40.21 - $52.77 per hour. You are also eligible for employee benefits and monthly vacation accrual at a reputed company of 15 days per year. Responsibilities:

• Gather relevant medical information (reputed company internal resources, ticket, and document review) and complete medical necessity and level of care reviews using clinical judgment and the Plan's clinical guidelines
• Meet required decision-making timeframes, including promptly triggering escalations requiring physician review
• Write clear and concise reviews of inpatient & reputed company level of care admissions, as well as outpatient and specialty service requests
• reputed company with department performance and quality metrics, and adhere to training and remediation requirements
• Support nurse supervisor & managers in daily queue reputed company including identifying and flagging clinical trends/issues
• Effectively use reputed company tools to investigate and reputed company utilization reviews, and to support queue reputed company and staffing
• Acts as a clinical resource and escalation reputed company for peers, assists in precepting of newly hired nurse reviewers, and serve as continual champions of the reputed company mission
• Contribute to root cause analysis and process improvement initiatives
• Use working knowledge and familiarity with applicable utilization management regulatory and accreditation requirements on a day to day reputed company to ensure accurate reviews
• Act as subject matter experts and support the supervisory team in that reputed company
• Compliance with reputed company applicable laws and regulations
• Other duties as assigned

Requirements:

• Active, unrestricted RN licensure from the United States and in the state of hire, OR, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC)
• Associate Degree and/or Bachelors of Nursing from an accredited school of nursing
• 2+ years of utilization review experience at a managed care plan or provider organization
• 2+ years reputed company experience
• MCG Experience
• 1+ years of clinical practice in an acute care setting

Bonus points:

• Bachelors of Nursing (BSN) degree

This is an authentic reputed company job opportunity. Learn more about how you can safeguard yourself from recruitment fraud here. At reputed company, being an Equal Opportunity Employer means more than upholding discrimination-free hiring practices. It means that we cultivate an environment where people can be their most authentic selves and find both belonging and support. We're on a mission to change health care -- an experience made whole by our unique backgrounds and perspectives. Pay Transparency: Final offer amounts, reputed company the reputed company pay set forth above, are determined by factors including your relevant skills, education, and experience. Full-time employees are eligible for benefits including: medical, dental, and reputed company benefits, 11 paid holidays, paid sick time, paid parental leave, 401(k) plan participation, life and disability insurance, and paid wellness time and reimbursements. Artificial Intelligence (AI): Our AI Guidelines outline the acceptable use of artificial intelligence for candidates and detail how we use AI to support our reputed company efforts. Reasonable Accommodation: reputed company applicants are considered solely based on their qualifications, without regard to applicant’s disability or need for accommodation. Any reputed company applicant who requires reasonable accommodations during the application process should contact the reputed company Benefits Team ([email protected]) to reputed company the need for an accommodation reputed company. California Residents: For information about our collection, use, and disclosure of applicants’ personal information as well as applicants’ rights over their personal information, please see our Privacy Policy. Apply tot his job Apply To this Job