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Clinical Utilization Specialist

2 months ago

Atlanta, Georgia, United States Sonder Health Plans, Inc. Full time
Position Overview:

The role of the Healthcare Review Nurse is pivotal in ensuring that medical services are delivered with optimal quality, cost-effectiveness, and adherence to regulations. By systematically evaluating and auditing patient treatment records, the healthcare review nurse will safeguard against unnecessary procedures, ineffective treatments, and prolonged hospital stays.

Key Responsibilities:

Essential functions of this position include:
  • Conducting concurrent assessments of patient clinical data for efficiency
  • Continuously reviewing preauthorization requests to confirm medical necessity
  • Coordinating discharge planning needs for members as part of a collaborative care team
  • Utilizing expertise, critical thinking, and skills to:
    • Promote quality care and improved quality of life
    • Avert complications for members during hospital admissions
    • Advocate for reduced hospital stays when clinically appropriate
    • Actively engage in discharge planning processes, collaborating with assigned Case Managers for MLTC and SNP members, as well as the member's care team to ensure timely discharge, appropriate follow-up, and continuity of care.
  • Facilitating requests for Sub-Acute care, Durable Medical Equipment (DME), Home Health Care, and Transportation services for members.
  • Referring cases with quality-of-care issues to the Chief Medical Officer and Quality Assurance Department.
Qualifications:
  • Excellent interpersonal and communication skills, with the ability to effectively engage a diverse range of stakeholders.
  • Capability to plan, implement, and assess individualized member care programs.
  • Familiarity with medical billing processes.
  • Proficient in Microsoft Office Suite and Google applications.
  • Adept at managing a substantial workload in a fast-paced, results-oriented environment.
  • Experience in Medicare Managed Care utilization management and relevant regulations.
  • Dedication to maintaining knowledge and compliance with departmental policies, CMS requirements, NCQA, AAHC, and applicable Federal and State guidelines.
  • Commitment to ethical practices in daily operations, demonstrating professionalism and inspiring high levels of engagement and teamwork.
  • Valid State licensure as a Practical Nurse (LPN) in good standing.
  • At least one year of prior experience conducting utilization reviews for a Health Maintenance Organization (HMO).
Working Conditions:
  • Minimal physical effort required.
  • Work environment involves limited exposure to physical risks, such as operating hazardous equipment or handling chemicals.
  • The company employs a hybrid work model based on position requirements, performance, productivity, and organizational needs, which may be adjusted as necessary.
Equal Employment Opportunity:

Sonder Health Plans is an Equal Opportunity Employer. The Company is committed to providing equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.

Sponsorship in the U.S.:

Must be eligible to work in the U.S. without sponsorship.