Utilization Review Nurse

🔥 4 minutes ago

🇺🇸 United States – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

👻 Ghost score 10%

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Peak Health

WebsiteLinkedInAll Job Openings

51 - 200 employees

🏥 Healthcare

💼 Consulting

🛡️ Insurance

Healthcare • Consulting • Insurance

Peak Health is a health insurer and health insurance services company headquartered in Morgantown, West Virginia. It is owned by three not-for-profit health care providers: WVU Health System, Marshall Health Network, and Valley Health. Peak Health aims to improve community health outcomes by offering an inclusive, provider-led health plan for residents of West Virginia and surrounding areas. The company is committed to making health care more accessible, understandable, and collaborative, with a focus on reducing costs and administrative fees for patients and employers. Peak Health also offers Medicare Advantage coverage tailored for West Virginia seniors through partnerships with leading health systems.

📋 Description

• Collaborate with the Medical Director to decrease care variance and ensure timely discharges • Refer members to other health plan resources to meet their care conditions • Report to the Health Plan Manager of Utilization Management • Serve as an integral and collaborative member of the health plan’s medical management team • Assist with building and implementing care management review processes, including Prior Authorization, Predetermination, Concurrent Reviews, and Retrospective Reviews • Implement care management reviews according to established criteria, clinical guidelines, and policies • Ensure interventions are collaborative and focused on maximizing member healthcare outcomes • Work with Medical Directors to improve the Peer-to-Peer Review process and member and Provider Network services • Educate internal and external stakeholders and partners • Collaborate with the medical management team to identify members who may benefit from coaching or case management interventions • Understand collected data and work with team members to improve outcomes • Participate in lifelong learning and continuous process improvement across Utilization Management

🎯 Requirements

• Current Registered Nurse license issued by the state in which services will be provided or current multi-state Registered Nurse license through the enhanced Nurse Licensure Compact (eNLC) • Three (3) years of healthcare clinical experience • Working knowledge of InterQual and/or Milliman Care Guidelines • Demonstrated knowledge of federal and state laws, NCQA and industry regulations related to disease management, utilization management, case management and discharge planning • Excellent written and oral communication • Problem solving capabilities to drive improved efficiencies and customer satisfaction • Attention to detail • Proficiency with Microsoft Office • Occasional weekend and holiday work may be required • Preferred: Bachelor's Degree in Nursing OR Associate of Science in Nursing Degree (ASN); currently enrolled in a BSN program and BSN completion within three (3) years of hire • Preferred: Medical Management experience for Medicare and/or Medicaid populations • Preferred: Utilization Management experience

🏖️ Benefits

• Full-time schedule with 40 scheduled weekly hours • Exempt status • Remote work location • Occasional weekend and holiday work may be required