Utilization Management Nurse

Utilization Management Nurse

Remote

Our Mission is to Make Healthcare Right. Together. Built upon the belief that by connecting and aligning the best local resources in healthcare delivery with the financing of care, we can deliver a superior consumer experience, lower costs, and optimized clinical outcomes.

What drives our mission? The company values we live and breathe every day. We keep it simple: Be Brave. Be Brilliant. Be Accountable. Be Inclusive. Be Collaborative.

If you share our passion for changing healthcare so all people can live healthy, brighter lives apply to join our team.

SCOPE OF ROLE

The role of the UM Nurse is to promote quality, cost-effective outcomes for a population by facilitating collaboration and coordination across settings, identifying member needs, planning for care, monitoring the efficacy of interventions, and advocating to ensure members receive the services and resources required to meet desired health and social outcomes. The UM Nurse is responsible for providing patient-centered care across the care continuum.

ROLE RESPONSIBILITIES

• Capacity to perform prospectively, retrospective, or concurrent medical necessity reviews for an assigned panel of members
• Capacity to review cases for medical necessity and apply the appropriate clinical criteria; to include, but not limited to Medicare criteria, Medicaid/Medi-cal criteria, Interqual, Milliman, or Health Plan specific guidelines
• Capacity to collaborate with the Medical Director to ensure the integrity of adverse determination notices based on the quality standards for adverse determinations
• Capacity to ensure discharge planning is timely and appropriately communicated to the transition of care teams, when applicable.
• Capacity to meet or exceed productivity targets set forth
• Capacity to serve as a resource to non-clinical team members when applicable
• Adheres to the Policies and Procedures set forth by the Quality Management Committee.

EDUCATION, TRAINING, AND PROFESSIONAL EXPERIENCE

• Associate’s degree in Nursing, preferred
• Minimum 2 years of experience in medical management clinical functions.
• Working knowledge of MCG, InterQual, and NCQA standards

LICENSURES AND CERTIFICATIONS

• Active and Unrestricted License as a Licensed Vocational Nurse (LVN)
• Certification Managed Care Nursing (CMCN) preferred

WORK ENVIRONMENT

• The majority of work responsibilities are performed in an open office setting, carrying out detailed work sitting at a desk/table and working on the computer.
• Some travel may be required.
• Ability to lift at least 50 pounds.

We’re Making Healthcare Right. Together.

We are realizing a completely different healthcare experience where payors, providers, doctors, and patients can all feel connected, aligned and unified on the same team. By eradicating the frictions of competing needs, we are making it possible to give everyone more of what they want and deserve. We do this by:

Focusing on Consumers
We understand patient pain points, eliminating complexity while increasing transparency, for greater access and easier navigation.

Building on Alignment
We integrate and align individual incentives at all levels, from financing to optimization to delivery of care.

Powered by Technology

We employ our purpose built, integrated data platform to connect clinical, financial, and social data, to deliver exceptional outcomes.

As an Equal Opportunity Employer, we welcome and employ a diverse employee group committed to meeting the needs of Bright Health, our consumers, and the communities we serve. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.