Utilization Review Nurse
2 days ago
At Sonder Health Plans, we are seeking a skilled Utilization Review Nurse to join our team. As a Utilization Review Nurse, you will play a critical role in ensuring that healthcare services are administered with quality, cost efficiency, and within compliance.
Key Responsibilities:- Conduct concurrent reviews of member clinical information to ensure efficiency and effectiveness of care.
- Review preauthorization requests for medical necessity and coordinate member discharge planning needs as part of an integrated care team.
- Employ effective use of knowledge, critical thinking, and skills to advocate quality care and enhanced quality of life for members.
- Participate in discharge planning processes, engaging assigned Case Manager for MLTC and SNP members as well as the members care team to ensure timely discharge, appropriate follow-up, and continuity of care.
- Facilitate requests for Sub-Acute care, DME, Home Health Care, and Transportation for members.
- Refer cases with quality-of-care concerns to the CMO and Quality Department.
- Strong interpersonal and communication skills and the ability to work effectively with a wide range of constituencies in a diverse community.
- Ability to plan, implement, and evaluate individual member care programs.
- Knowledge of medical billing procedures.
- Intermediate skills in Microsoft Office suite and Google.
- Ability to manage a large workload and thrive in a results-driven, fast-paced environment.
- Experience with Medicare Managed Care utilization management and applicable regulations.
- Commitment to maintain working knowledge and compliance with departmental policies & procedures, CMS requirements, NCQA, AAHC, as well as Federal & State guidelines, as applicable.
- Ability to practice ethics in daily operations, demonstrating professionalism and commitment to success, inspiring others towards high-level of engagement and teamwork.
- State licensure as a Practical Nurse (LPN) in good standing.
- Minimum 1-year prior experience completing utilization reviews for an HMO.
No or very limited physical effort required. Work environment involves minimal exposure to physical risks, such as operating dangerous equipment or working with chemicals.
Sonder Health Plans is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide 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.
Must be eligible to work in the U.S. without Sponsorship.
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