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Clinical Utilization Nurse II

2 months ago

Bellevue, Washington, United States Hma INC Full time

HMA is recognized as a leading third-party health plan administrator throughout the Pacific Northwest and beyond. We are committed to fulfilling our promise of delivering tailored health plans to medium and large employers. Our offerings include a variety of high-quality, cost-effective healthcare plan options, all backed by exceptional customer service.

We take pride in being named one of 'Washington's Best Workplaces' for three consecutive years by our staff and the Puget Sound Business Journal. Our vision, 'Proving What's Possible in Healthcare,' along with our core values—People First, Be Extraordinary, Work Courageously, Own It, and Win Together—are integral to our culture, guiding our decisions and driving our success.

What we seek: We are continuously on the lookout for distinctive individuals to join our team. We hire only those who are genuinely compassionate, thrive in dynamic environments, find fulfillment in teamwork, are driven by complex challenges, possess the courage to share innovative ideas, and are results-oriented.

What you can anticipate: Expect an inclusive, flexible, and enjoyable workplace culture, along with a comprehensive salary and benefits package that emphasizes pay transparency, ample time off, and numerous opportunities for personal and professional growth. If you desire meaningful work with a clear purpose, high standards, work-life balance, and the chance to contribute to significant initiatives, we encourage you to learn more about us.

Your Impact:

The Clinical Utilization Nurse collaborates with external partners, including Brokers and Group Contacts, to provide timely updates on case specifics while adhering to HIPAA regulations. This role is crucial for ensuring the effective utilization of health services by monitoring member usage and claims patterns, and making referrals to Case Manager nurses for ongoing management of complex care.

Your Responsibilities:

  • Conduct Utilization Management by first reviewing the terms of the Summary Plan Description (SPD), taking into account any benefit limitations/exclusions and the PPO status of the requesting provider/facility.
  • Perform reviews using established criteria to assess the appropriateness of services, care settings, and length of stay.
  • Provide ongoing management of treatment progress as necessary to ensure personalized support and care coordination for complex, catastrophic, or chronic medical conditions.
  • Evaluate requested services to align with individual healthcare needs, aiming to deliver tailored management that promotes continuity of care.
  • Other responsibilities as assigned.

Qualifications for Success:

  • Associate's degree or equivalent professional experience required.
  • Active LPN/RN clinical license required.
  • 3-5+ years of clinical nursing experience.
  • Knowledge of Utilization Review processes is preferred.
  • Strong clinical practice experience with diverse diagnoses.
  • Excellent problem-solving and critical thinking abilities.
  • Outstanding verbal and written communication skills, particularly in client-facing situations.
  • Behavioral health experience is preferred.
  • Self-motivated and self-directed.
  • Ability to thrive in a deadline-driven environment with strong prioritization skills.
  • Proficient in Electronic Health Records and Microsoft Office applications (Outlook, Word, DOSS).

Compensation:

The base salary range for this position in the greater Seattle area is $85,000 - $105,000, varying based on geography, skills, experience, education, and other job-related factors. Performance-based incentives are available. Additionally, HMA offers a generous total rewards package for full-time employees, including: seventeen days of paid time off; eleven paid holidays; one paid personal day; company-subsidized medical, dental, vision, and prescription insurance; company-paid disability, life, and AD&D insurances; voluntary life insurance; HSA and FSA pre-tax programs; a 401(k) retirement plan with company match; wellness incentives; remote work options; continuing education reimbursements; a discount program; parental leave; and a charitable giving match.

Supporting Your Work, Life, and Wellness Goals:

We provide a comprehensive total rewards package that includes competitive pay, annual incentives, wellness programs, medical, dental, and vision insurance, a 401K retirement plan with matching contributions, generous PTO and holidays, an onsite gym, life and disability insurances, an Employee Assistance Plan with additional mental health support, free parking, and easy access to major freeways. We also offer a stocked kitchen with subsidized snacks and refreshments, year-round wellness activities, monthly events, paid volunteer hours, and more.

HMA primarily operates as a remote workforce, requiring a reliable internet connection, and provides all necessary hardware. Some roles may require onsite presence a few days per month, while others are fully remote.

A background check prior to employment is mandatory.

HMA is an Equal Opportunity Employer.