What are the responsibilities and job description for the UTILIZATION MANAGEMENT NURSE position at Sonder Health Plans, Inc.?
Sonder Health Plans
Atlanta, GA
Full-time
Hybrid
At Sonder Health Plans, we believe the healthcare system should be accessible, transparent, and easy to navigate. As a full-stack, technology-driven health plan, we are creating a customer-centric experience that gets our members the care they need when they need it. If you want to be part of the future of healthcare, we'd love for you to join us.
Sonder Health Plans is looking for a full-time Utilization Management Nurse to make sure our health services are administered efficiently and effectively. The main goal of this position is to provide operational support and clinical expertise in the areas of health care services, member benefits and clinical operations for all of Sonder Health Plans members to improve member and provider satisfaction as well as the quality of care and health outcomes for members.
Primary Responsibilities :
- Determine the appropriateness of inpatient and outpatient services following the evaluation of medical guidelines and benefit determinations
- Identify and report any quality of care concerns that occur while members are in acute care and / or skilled nursing facilities.
- Support Sonder Health Plan's compliance to regulatory accreditation requirements for both state and federal agencies
- Support quality audits, chart audits and reviews of medical records as needed for either complex high cost cases or cases with quality of care issues
- Coordinate case management on complex cases that require additional clinical management support
- Conducts initial review of prior authorization or pre-certification requests for determination of coverage for members covered by sponsored health benefit plans
- Makes determinations based on medical necessity of plan-covered services based on internal policies reviewed and approved by the Chief Medical Officer of the plan
- Where appropriate, involves the Chief Medical Officer if a partial or fully adverse medical necessity determination is expected based on the initial review
- Works collaboratively with the Director of Health Services to achieve all UM targets on a monthly basis
- Participates in and supports all medical management initiatives including, but not limited to : ER visits, readmissions, OOA utilization and identification of potential high cost cases
- Collaborates with care managers on care transitions for patients with an emphasis on high risk patients at risk for readmission, on an as needed basis
- Responsible for planning and monitoring departmental activities and needs, collection and analysis of performance data, and performance management of Managers and other staff reporting to this position.
- Responsible for meeting staffing needs, vendor oversight, associate development, and performance assessment of all direct and indirect reports.???????
- Perform additional duties as requested.
Required Qualifications :
Preferred Qualifications :
Equal Employment Opportunity
Sonder Health Plans is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.
Sponsorship in US
Must be eligible to work in the U.S. without Sponsorship
Why You Should Join Us :
Job Type : Full-time
