Utilization Management Nurse

🔥 3 minutes ago

🇺🇸 United States – Remote

⏰ Full Time

🟢 Junior

🟡 Mid-level

👻 Ghost score 10%

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Curana Health

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

🏥 Healthcare

🤝 B2B

⚕️ Healthcare Insurance

Healthcare • B2B • Healthcare Insurance

Curana Health is a healthcare provider focused on senior primary care and on-site clinical services in skilled nursing and senior living communities. The company partners with operators, payors, and Medicare Advantage plans to implement value-based care models, offering physician-led care teams, medical director services, care coordination (including RPM and APCM), behavioral health, and palliative care. Curana emphasizes reducing hospital readmissions, falls, and polypharmacy while improving resident satisfaction through integrated, community-based care supported by technology and payor partnerships.

📋 Description

• Review and monitor members' utilization of health care services to maintain high-quality, cost-effective care • Evaluate the appropriateness and efficiency of medical services and procedures • Provide prior authorizations, concurrent review, proactive discharge/transition planning, and high-dollar claims review • Perform concurrent and retrospective reviews on facility and appropriate home health services • Monitor level and quality of care and proactively manage acutely and chronically ill patients • Evaluate and provide feedback regarding discharge plans, covered services, and alternative levels of care • Determine observational versus acute inpatient status during hospital prior authorization • Engage providers in proactive discharge and transition planning • Prepare CMS-compliant notification letters and review non-certification files • Maintain accurate records of communications and monitor utilization reports for compliance and turnaround times • Coordinate interdisciplinary care and continuity of care • Issue appropriate authorizations for covered services • Identify and report potential high-dollar/utilization cases for reserve allocation • Recommend cost savings and quality-of-care improvements • Clarify health plan benefits, policies, and procedures for members and providers • Identify members for potential Chronic Care Improvement Program inclusion • Identify and report potential quality-of-care concerns • Work as an interdisciplinary team member within Medical Management and across departments

🎯 Requirements

• Minimum 2 years clinical experience as RN, LPN/LVN required • Minimum 1-year managed care or equivalent health plan experience preferred • Demonstrated experience in health plan utilization management, facility concurrent review discharge planning, and transfer coordination required • Medicare Advantage experience preferred • Experience with InterQual or MCG authorization criteria preferred • Excellent computer skills and ability to learn new systems required • Strong attention to detail, organizational skills and interpersonal skills required • Demonstrated ability to problem solve and manage professional relationships • Active unrestricted Nursing license required • Company unable to provide sponsorship for a visa at this time (H1B or otherwise)

🏖️ Benefits

• Primarily remote telephonic position • Normal business day hours • One weekend day per month coverage • Opportunity to contribute to improving the health, happiness, and dignity of older adults • Equal Employment Opportunity commitment