2 USRN - Utilization Management Jobs in Aliso Viejo, CA
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USRN - Utilization Management
$74k-98k (estimate)
Full Time
4 Weeks Ago
UST Healthproof is Hiring an USRN - Utilization Management Near Aliso Viejo, CA
Role DescriptionUSRN - Utilization ManagementLead II – BPMWho We AreUST HealthProof is a dynamic company with a mission to lower the cost of care and deliver the future of healthcare. Our consumer-centric approach gives our health plan customers a modern infrastructure and reduced administrative costs, helping to drive better business results for our customers — and better outcomes for our communities.
We achieve this mission together through teamwork, communication, collaboration, and focus. Our employees are our greatest assets, and we invite you to apply to be a part of our journey toward making a difference in healthcare in the United States.
You AreUST is searching for a USRN - Utilization Management who will perform prospective, concurrent, and retrospective reviews of inpatient, outpatient, ambulatory and ancillary services to ensure medical necessity, appropriate length of stay, the intensity of service, and level of care, including appeal requests initiated by providers, facilities, and members. Review, research, and prepare documentation related to retrospective review requests and appeals in accordance with local, state, and federal regulatory and designated accreditation (e.g., NCQA) standards.
The Opportunity
What You Need
Role Location: RemoteCompensation Range: $60,000-$90,000Our full-time, regular associates are eligible for 401K matching, and vacation accrual and are covered from day 1 for paid sick time, healthcare, dental, vision, life, and disability insurance benefits.
What We BelieveWe’re proud to embrace the same values that have shaped UST HealthProof since the beginning. Since day one, we’ve been building enduring relationships and a culture of integrity. And today, it's those same values that are inspiring us to encourage innovation from everyone, to champion diversity and inclusion, and to place people at the center of everything we do.
HumilityWe will listen, learn, be empathetic and help selflessly in our interactions with everyone.
HumanityThrough business, we will better the lives of those less fortunate than ourselves.
IntegrityWe honor our commitments and act with responsibility in all our relationships.
Equal Employment Opportunity StatementUST HealthProof is an Equal Opportunity Employer.
All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.
UST HealthProof reserves the right to periodically redefine your roles and responsibilities based on the requirements of the organization and/or your performance.
#Healthproof
#CB
SkillsHealthcare,Utility Management,Claims
We achieve this mission together through teamwork, communication, collaboration, and focus. Our employees are our greatest assets, and we invite you to apply to be a part of our journey toward making a difference in healthcare in the United States.
You AreUST is searching for a USRN - Utilization Management who will perform prospective, concurrent, and retrospective reviews of inpatient, outpatient, ambulatory and ancillary services to ensure medical necessity, appropriate length of stay, the intensity of service, and level of care, including appeal requests initiated by providers, facilities, and members. Review, research, and prepare documentation related to retrospective review requests and appeals in accordance with local, state, and federal regulatory and designated accreditation (e.g., NCQA) standards.
The Opportunity
- Contact appropriate medical and support personnel to identify and recommend an alternative treatment, service levels, length of stays, etc. using approved clinical protocols.
- Follow out-of-area/out-of-network services and make recommendations on patient transfer to in-network services and/or alternative plans of care.
- May establish care plans and coordinate care through the health care continuum including member outreach assessments.
- Establish, coordinate, and communicate discharge planning needs with appropriate internal and external entities.
- Review patterns of care associated with disease progression; identify contractual services and organize delivery through appropriate channels.
- Research and resolve issues related to benefits, member eligibility, non-elective and non-authorized services, coordination of benefits, care coordination as needed.
- Develop and deliver targeted education for the provider community related to policies, procedures, benefits when appropriate.
What You Need
- Registered Nurse with current, unrestricted US Registered Nurse license
- 3 years of direct, clinical nursing experience
- 2 years’ experience in US Healthcare in utilization management or case management
- MCG Certification will be a plus
- Healthedge HRCM or Guiding Care experience is a plus
Role Location: RemoteCompensation Range: $60,000-$90,000Our full-time, regular associates are eligible for 401K matching, and vacation accrual and are covered from day 1 for paid sick time, healthcare, dental, vision, life, and disability insurance benefits.
What We BelieveWe’re proud to embrace the same values that have shaped UST HealthProof since the beginning. Since day one, we’ve been building enduring relationships and a culture of integrity. And today, it's those same values that are inspiring us to encourage innovation from everyone, to champion diversity and inclusion, and to place people at the center of everything we do.
HumilityWe will listen, learn, be empathetic and help selflessly in our interactions with everyone.
HumanityThrough business, we will better the lives of those less fortunate than ourselves.
IntegrityWe honor our commitments and act with responsibility in all our relationships.
Equal Employment Opportunity StatementUST HealthProof is an Equal Opportunity Employer.
All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.
UST HealthProof reserves the right to periodically redefine your roles and responsibilities based on the requirements of the organization and/or your performance.
#Healthproof
#CB
SkillsHealthcare,Utility Management,Claims
Job Summary
JOB TYPE
Full Time
SALARY
$74k-98k (estimate)
POST DATE
05/27/2024
EXPIRATION DATE
07/26/2024
WEBSITE
usthealthproof.com
SIZE
<25
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