Utilization Management Nurse

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Vālenz® Health

WebsiteLinkedInAll Job Openings

501 - 1000 employees

Founded 2004

🏥 Healthcare

💼 Consulting

📦 Logistics

Healthcare • Consulting • Logistics

Vālenz® Health is a comprehensive health plan solutions provider that offers a fully integrated platform designed to simplify the complexities of healthcare for employers, payers, providers, and members. The company focuses on enhancing quality and lowering costs through data-driven insights, member navigation, provider networks, and robust claims management. By connecting various stakeholders in the healthcare ecosystem, Vālenz aims to improve health outcomes and streamline the healthcare experience for all involved.

📋 Description

• Oversee and manage the Utilization Management process to ensure appropriate, necessary, and cost-effective healthcare delivery • Conduct timely prospective, concurrent, and retrospective Utilization Management reviews • Apply summary plan documents and other resources to utilization requests • Collaborate with appropriate parties to apply correct Utilization Management criteria within required timelines • Promote quality care and cost-effective outcomes for plan participants • Ensure compliance with CMS, URAC, and other regulatory standards and guidelines • Identify and report potential overutilization, underutilization, or improper utilization • Identify potential catastrophic, high-risk, and disease management cases and refer them to the appropriate team • Communicate Utilization Management decisions and recommendations to providers and plan participants • Maintain complete, accurate, and confidential Utilization Management records • Participate in ongoing Utilization Management education and training • Maintain confidentiality in accordance with HIPAA • Assure continuity of inpatient care through early discharge planning • Identify and communicate potential quality-of-care and patient-safety issues to the Quality Improvement Coordinator • Perform other duties as assigned

🎯 Requirements

• 3+ years of clinical nursing experience • Active, unrestricted RN license in the state of residence • Ability to work in a fast-paced, detailed, deadline-driven environment • Ability to maintain strict confidentiality and handle sensitive information with discretion • Experience working independently • Strong problem-solving and organizational skills • Strong relationship-building aptitude and highly effective communication style • Utilization Management or Case Management Certification is a plus • Quiet workspace free from distractions • Reliable internet connection • Adherence to company security protocols, including VPNs, secure passwords, and company-approved devices/software • Must be US based • Ability to work Monday through Friday during standard business hours aligned to the applicable time zone • Compliance with HIPAA and company policies

🏖️ Benefits

• Generous compensation commensurate with experience and performance • Competitive benefits package with generous employer subsidies • Flexible and remote working options • 401k with generous employer match and immediate vesting • Personal and professional development opportunities • Supportive family benefits, including paid leave for new family members • Companywide philanthropic program, Valenz Communities Connection • Necessary equipment provided • Generously subsidized company-sponsored Medical, Dental, and Vision insurance • Access to services through Healthcare Blue Book and KISx Card • HSA, FSA, and DCFSA spending account options • Flexible working environment • Generous Paid Time Off, including vacation, sick leave, and paid holidays • Employee Assistance Program including professional counseling, referrals, and additional services • Paid maternity and paternity leave • Pet insurance • Employee discounts on phone plans, car rentals and computers • Community giveback opportunities, including paid time off for philanthropic endeavors