Utilization Management Nurse – Part-Time

Job not on LinkedIn

🕒 September 16

🍂 Massachusetts – Remote

🍂 Massachusetts – Remote

💵 $38 - $40 / hour

⏱ Part Time

🟢 Junior

🟡 Mid-level

👻 Ghost score 8%

What it means: the chance that no one is really hiring for this job.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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nirvanaHealth | RxAdvance

WebsiteLinkedInAll Job Openings

51 - 200 employees

Founded 2013

🏥 Healthcare

⚕️ Healthcare Insurance

☁️ SaaS

💰 $60M Later Stage VC on 2022-03

Healthcare • Healthcare Insurance • SaaS

nirvanaHealth | RxAdvance is a cloud-native Payer and pharmacy benefit manager (PBM) platform provider that leverages robotic process automation (RPA) to integrate medical, pharmacy, and behavioral services. The company provides a SaaS platform aimed at payers and PBMs to reduce administrative and medical costs, improve care quality, manage compliance, and deliver comprehensive clinical, pharmacy, and administrative services. NirvanaHealth focuses on healthcare automation and payer/PBM operational transformation through RPA-driven workflows and risk management capabilities.

📋 Description

• Perform prospective, concurrent, and retrospective medical necessity reviews for healthcare products and services • Perform level-of-care determinations and monitor length of stay using appropriate clinical criteria • Conduct initial clinical reviews in accordance with accreditation, laws, and regulations • Ensure regulatory and accreditation guidelines are met for review timeliness • Verify accuracy of codes and services and maintain appropriate documentation • Coordinate discharge planning and transitions of care with registered nurse case managers and healthcare team members • Communicate member, provider, and facility notifications, including clinical criteria and Medical Director denial rationale when indicated • Collaborate with multidisciplinary staff and interdepartmental teams • Establish and maintain professional relationships with providers and facilities • Evaluate, coordinate, manage, and document utilization-management activities • Maintain current knowledge of medical necessity criteria and UM policies and procedures • Assist with development and maintenance of medical necessity criteria and clinical pathways • Monitor effectiveness and outcomes of the utilization-management program • Participate in UM program process-improvement initiatives • Comply with utilization-management, case-management, regulatory, accreditation, and standards-of-practice requirements • Perform other duties as assigned

🎯 Requirements

• Associate's degree in nursing required • Bachelor’s degree in nursing preferred • 0–2 years of prior experience in utilization management or case management preferred • Knowledge of Medicare preferred • Knowledge of Medicaid, HMO, and private insurance preferred • Knowledge of accreditation standards, including NCQA and URAC, preferred • Current active, unrestricted state licensure as a Registered Nurse required • Utilization Management or Case Management certification preferred • Professional license must have a scope of practice relevant to initial clinical review • Strong clinical background and solid clinical judgment required • Strong PC skills, including MS Word, Excel, Access, and PowerPoint • Ability to pass a background investigation

🏖️ Benefits

• Competitive benefits • Employee wellness focus • Support for employee growth • Remote work arrangement

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