Utilization Management Nurse

Job Description

Job Description

Vālenz® Health is the platform to simplify healthcare – the destination for employers, payers, providers and members to reduce costs, improve quality, and elevate the healthcare experience. The Valenz mindset and culture of innovation combine to create a distinctly different approach to an inefficient, uninspired health system. With fully integrated solutions, Valenz engages early and often to execute across the entire patient journey – from care navigation and management to payment integrity, plan performance and provider verification. With a 99% client retention rate, we elevate expectations to a new level of efficiency, effectiveness and transparency where smarter, better, faster healthcare is possible.

About Our Opportunity

As a Utilization Management Nurse, you will play a vital role in delivering comprehensive, patient-centered care by assessing individual needs, developing personalized care plans, and fostering collaboration among healthcare providers. Using your clinical knowledge, you will guide patients through the healthcare system, support adherence to treatment plans, and advocate for high-quality outcomes through education, emotional support, and clear communication. You will also contribute to wellness promotion, effective use of resources, and compliance with both regulatory and organizational standards.

Things You’ll Do Here :

• Conduct timely reviews of UM activities, including prospective, concurrent, and retrospective reviews and apply to summary plan documents or other resources related to the request.
• Collaborate with appropriate parties to apply the correct UM criteria within the appropriate timelines.
• Promote quality care and cost-effective outcomes that enhance the physical, psychosocial, and vacation health of plan participants.
• Ensure compliance with regulatory standards and guidelines related to UM activities, such as those set forth by CMS, URAC, and other regulatory agencies.
• Identify and report cases of potential overutilization, underutilization, or improper utilization of healthcare services.
• Identify potential catastrophic, high-risk, and disease management cases and refer cases to the appropriate team.
• Communicate UM decisions and recommendations to healthcare providers and plan participants.
• Maintain accurate and complete records of UM activities and ensure confidentiality of sensitive information.
• Participate in ongoing UM education and training to stay up-to-date with industry developments.
• Maintain a high level of confidentiality in accordance with HIPAA.
• Maintain an active role in assuring continuity of care for all inpatients through early discharge planning.
• Identify and communicate to the Quality Improvement Coordinator potential quality of care and patient safety issues.
• Perform other duties as assigned.

Reasonable accommodation may be made to enable individuals with disabilities to perform essential duties.

What You’ll Bring to the Team :

A plus if you have :

Where You’ll Work :

This is a fully remote position, and we’ll provide all the necessary equipment!

Why You'll Love Working Here

Valenz is proud to be recognized by Inc. 5000 as one of America’s fastest-growing private companies. Our team is committed to delivering on our promise to engage early and often for smarter, better, faster healthcare . With this commitment, you’ll find an engaged culture – one that stands strong, vigorous, and healthy in all we do.

Benefits

At Valenz, we celebrate, support, and thrive on inclusion, for the benefit of our associates, our partners, and our products. Valenz is committed to the principle of equal employment opportunity for all associates and to providing associates with a work environment free of discrimination and harassment. All employment decisions at Valenz are based on business needs, job requirements, and individual qualifications, without regard to race, color, religion or belief, national, social, or ethnic origin, sex (including pregnancy), age, physical, mental or sensory disability, HIV Status, sexual orientation, gender identity and / or expression, marital, civil union or domestic partnership status, past or present military service, family medical history or genetic information, family or parental status, or any other status protected by the laws or regulations in the locations where we operate. We will not tolerate discrimination or harassment based on any of these characteristics.

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