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Clinical Operations Specialist
1 month ago
Sonder Health Plans is seeking a highly skilled Utilization Management Nurse to join our team. As a key member of our clinical operations team, you will play a critical role in ensuring the efficient and effective administration of our health services.
Key Responsibilities:
- Determine the appropriateness of inpatient and outpatient services based on medical guidelines and benefit determinations
- Identify and report quality of care concerns while members are in acute care and/or skilled nursing facilities
- Support Sonder Health Plan's compliance with regulatory accreditation requirements for state and federal agencies
- Coordinate case management on complex cases requiring additional clinical management support
- Conduct initial reviews of prior authorization or pre-certification requests for determination of coverage for members covered by sponsored health benefit plans
Requirements:
- ADN, BSN, or Diploma nursing degree
- Minimum two (2) years of experience in case management and/or denials/appeals
- Minimum five (3-5) years of experience working in a managed care environment with Medicare Advantage/Commercial populations, utilization management experience, and acute clinical nursing experience
- Active Georgia Registered Nursing license
- Pre-authorization and Concurrent review experience
- Medical record investigative review knowledge
- Proficient computer skills (e.g., Word, Outlook, Excel, etc.) and utilizing the internet
- Strong professional communication with an acceptable use of English (verbally and in writing)
- Ability to work independently with limited supervision
- Capable of working with people of diverse backgrounds
- Demonstrates adaptability and openness to alternative solutions and flexibility when interacting with internally with the team and externally with members
- Excellent customer service skills and great telephone etiquette
Preferred Qualifications:
- Commercial or managed care payer background (Preferred)
- ACM, CCM, CPUR, CPUM, IQCI (Preferred)
About Sonder Health Plans:
Sonder Health Plans is an Equal Opportunity (EEO) employer. We are 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.
Why Work with Us:
At Sonder Health Plans, we offer a positive, start-up environment with limitless career growth opportunities. Our team is passionate about delivering exceptional customer service and making a meaningful impact in the lives of our members. If you're a motivated and dedicated professional looking for a challenging and rewarding role, we encourage you to apply.
