Clinical Quality Specialist
4 weeks ago
The Utilization Review Nurse is a critical member of our team at Sonder Health Plans, Inc. The ideal candidate will possess strong clinical knowledge, excellent communication skills, and the ability to work effectively in a fast-paced environment.
As a Utilization Review Nurse, you will be responsible for ensuring that health care services are administered with quality, cost efficiency, and within compliance. You will continuously review and audit member treatment records to ensure that members do not receive unnecessary procedures, ineffective treatment, or experience unnecessarily extensive hospital stays.
Key Responsibilities
- Concurrent review of member's clinical information for efficiency and medical necessity
- Ongoing review of preauthorization requests for medical necessity
- 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
- Prevent member complications during hospital stay
- Advocate for decreased hospital stay when appropriate
Qualifications
- 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
Working Conditions
No or very limited physical effort required. Work environment involves minimal exposure to physical risks, such as operating dangerous equipment or working with chemicals.
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