Utilization Management Nurse

Overview

Our mission is Better Health. Our passion is helping others.

What's Your Why?

• Are you looking for a career opportunity that will help you grow personally and professionally?
• Do you have a passion for helping others achieve Better Health?
• Are you ready to join a growing team that shares your mission?

Why Join Our Team : At Better Health Group, it's our commitment, our passion, and our culture that sets us apart. Our Team Members make a difference each and every day! They support our providers and payors, ensuring they have the necessary tools and resources to always deliver best-in-class healthcare experiences for our patients .

We don't just talk the talk - we believe in it and live by it. Be part of a team that shares your passion and drive, and start living your purpose at Better Health Group.

Responsibilities

Position Objective :

The Utilization Management Nurse is responsible for managing requests providing a multi-faceted approach to managing requests for medical services while ensuring the services are medically appropriate and necessary.

This role requires a multi-faceted approach, utilizing evidence-based clinical guidelines and input from healthcare providers.

The incumbent will report to the Dir Utilization Mgmt (or similar role) and will work towards achieving high-quality, cost-efficient medical outcomes for patients requiring in-patient care and outpatient procedures.

Responsibilities :

• Assess each request for medical services, considering factors such as medical necessity, appropriateness, and adherence to evidence-based clinical guidelines
• Utilize evidence-based clinical guidelines to make informed decisions regarding the approval or denial of requested medical services
• Collaborate with healthcare providers to gather input and seek their expertise in making utilization management decisions
• Communicate with healthcare providers, patients, and other stakeholders to gather necessary information, clarify any discrepancies, and provide updates on requested services
• Ensure compliance with regulatory requirements and internal policies to ensure all activities comply with regulatory requirements
• Monitor and track the utilization of medical services to identify trends, patterns, and opportunities for improvement and identify areas where cost-efficiency and quality of care can be optimized
• Collaborate with internal teams to develop and implement strategies for optimizing medical outcomes and cost-efficiency to meet organizations goals
• Provide education and support to healthcare providers regarding utilization management processes and guidelines
• Participate in quality improvement initiatives related to utilization management
• Contribute to the development, identify areas for improvement, and implement changes to enhance the overall quality of care
• Maintain accurate and up-to-date detailed records of all utilization management activities
• Additional duties as assigned

Position Requirements / Skills :

• Registered Nurse (RN) license in good standing within state of practice
• Bachelor's degree in Nursing or a related field, preferred
• 2 years of experience in Utilization Management
• Previous training and demonstrated competence in negotiations, Quality Assurance, and Case Management outcomes
• Demonstrated ability to solve complex, multifaceted, and emotionally charged situations
• Strong knowledge of evidence-based clinical guidelines and medical terminology
• Excellent critical thinking and decision-making skills
• Effective communication and interpersonal skills
• Ability to work independently and collaboratively in a fast-paced environment
• Proficiency in using computer systems and software for documentation and data analysis
• Proficient with Google Suite (Drive, Docs, Sheets, Slides) and Microsoft Office (Word, Excel, PowerPoint) for real-time collaboration

Physical Requirements :

• Ability to remain in a stationary position, often standing or sitting for prolonged periods of time
• Communicating with others to exchange information
• Repeating motions that may include the wrist, hands, and / or fingers
• Assessing the accuracy, neatness, and thoroughness of work assigned
• Must be able to lift at least 15lbs at times

Key Attributes / Skills :

• Has a contagious and positive work ethic, inspires others, and models the behaviors of core values and guiding principles
• An effective team player who contributes valuable ideas and feedback and can be counted on to meet commitments
• Is able to work within our Better Health environment by facing tasks and challenges with energy and passion
• Pursues activities with focus and drive, defines work in terms of success, and can be counted on to complete goals
• Demonstrated ability to handle data with confidentiality
• Ability to work cross-functionally with multiple teams; ability to work independently with minimal supervision
• Excellent organizational, time-management, and multi-tasking skills with strong attention to detail
• Excellent written and verbal communication skills; must be comfortable communicating with providers and patients
• Strong interpersonal and presentation skills
• Strong critical thinking and problem-solving skills
• Must be results-oriented with a focus on quality execution and delivery
• Appreciation of cultural diversity and sensitivity toward target patient population

Compensation & Benefits :

We offer competitive compensation and comprehensive benefits package :

• Competitive base salary with bonus potential upon placement / retention
• Medical, dental, vision, disability and life
• 401k, with employer match
• Paid time off
• Paid holidays

Pay Range

USD $63,650.00 - USD $95,450.00 / Yr.