Healthcare Utilization Specialist
4 days ago
This role is designed for a dedicated and compassionate Registered Nurse to join our team as a Healthcare Utilization Specialist. In this position, you will play a crucial part in ensuring that our clients receive high-quality healthcare services while adhering to federal and state regulations.
About Guidehealth
Guidehealth is a data-powered, performance-driven healthcare company committed to operational excellence. Our mission is to make great healthcare affordable, improve patient health outcomes, and restore the fulfillment of practicing medicine for healthcare providers.
Key Responsibilities:
- Perform utilization reviews in compliance with federal and state regulations and URAC standards for client members seeking healthcare treatment and services.
- Analyze and document all supporting clinical information within the documentation record.
- Complete timely reviews of healthcare services using and documenting the appropriate medical criteria to make clinical determinations.
- Communicate pre-certifications and concurrent review determinations for healthcare services to all required parties according to regulations, URAC standards, and Guidehealth policies.
- Collaborate with the Medical Director and Peer Reviewer(s) on cases requiring review of medical necessity, appropriate treatment, intensity/number of inpatient and outpatient treatment or quality of care issues.
- Maintain confidentiality of member information, case records, and file entries.
- Participate in quality management activities.
Requirements:
- Active and unrestricted RN license in Illinois required.
- Five years of experience in various healthcare settings.
- Knowledge of utilization review, managed care, and community health.
- Computer skills including MS Word, Excel, MS Access, etc.
- Strong organizational, writing, and speaking skills necessary.
- Excellent clinical judgment, compassion, and positive attitude.
Benefits and Compensation:
- $75,000 per year paid bi-weekly according to standard payroll practices.
- Comprehensive Medical, Dental, and Vision plans.
- 401(k) plan with 3% employer match.
- Life and Disability insurance.
- Employee Assistance Program (EAP).
- Flexible Time Off tailored to meet individual needs.
- Paid parental leave.
- Ongoing professional growth opportunities.
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