Utilization Review RN

Utilization Review – RN

Lead II – BPM

Who we are:

Advantasure is a growing company and a member of the UST HealthProof family, Advantasure champions innovative solutions with an eye on the future—providing health plans with the flexibility to adapt to a changing regulatory environment and evolving business needs. Leveraging the industry’s leading experts in government-sponsored health plans, Advantasure offers solutions for administrative cost management, quality patient outcomes and experiences, enrollment growth, risk adjustment and quality and provider engagement initiatives.

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 Are:

Perform prospective, concurrent and retrospective review of inpatient, outpatient, ambulatory and ancillary services to ensure medical necessity, appropriate length of stay, intensity of service and level of care, including appeal requests initiated by providers, facilities and members. May establish care plans and coordinate care through the health care continuum including member outreach assessments.

The Opportunity :

• Review, research and authorize requests for authorization of elective, direct, ancillary, urgent, emergency, etc. services. Contact appropriate medical and support personnel to identify and recommend alternative treatment, service levels, length of stays, etc. using approved clinical protocols.
• Analyze, research, respond to 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.
• Establish, coordinate and communicate discharge planning needs with appropriate internal and external entities.
• Analyze 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, etc.
• Identify and document quality of care issues; resolve or route to appropriate area for resolution.
• Follow out-of-area/out-of-network services and make recommendations on patient transfer to in-network services and/or alternative plans of care.
• Develop and deliver targeted education for provider community related to policies, procedures, benefits, etc.
As needed and in conjunction with Provider Services, may identify and negotiate reimbursement rates for non-contracted providers for services.

This position description identifies the responsibilities and tasks typically associated with the performance of the position. Other relevant essential functions may be required.

What you need:

• Registered Nurse with current unrestricted Registered Nurse license required.
• 2 years of clinical experience required
• 2 years Utilization Review exp required
• Demonstrated clinical knowledge and experience relative to patient care and health care delivery processes.
• 1 year health insurance plan experience or managed care environment preferred.
• Interqual/Milliman experience preferred
• Excellent written and verbal communication skills.
• Excellent customer service and interpersonal skills.
• Proficiency in MS Suite, especially Word, Excel and Outlook required.
• Ability to apply clinical criteria/guidelines for medical necessity, setting/level of care and concurrent patient management.
• Knowledge of current standard medical procedures/practices and their application as well as current trends and developments in medicine and nursing, alternative care settings and levels of service.
• Knowledge of policies and procedures, member benefits and community resources.
• Knowledge of applicable accreditation standards, local, state and federal regulations.
Other related skills and/or abilities may be required to perform this job based upon designated department assignment.

Compensation can differ depending on factors including but not limited to the specific office location, role, skill set, education, and level of experience. As required by applicable law, UST provides a reasonable range of compensation for roles that may be hired in various U.S. markets as set forth below.

Role Location: Remote

Compensation Range: $60,000-$90,000

Our 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 believe :

We’re proud to embrace the same values that have shaped UST and its subsidiaries 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 place people at the center of everything we do.

Humility:

We will listen, learn, be empathetic and help selflessly in our interactions with everyone.

Humanity:

Through business, we will better the lives of those less fortunate than ourselves.

Integrity:

We honor our commitments and act with responsibility in all our relationships.

Equal Employment Opportunity Statement

UST 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 reserves the right to periodically redefine your roles and responsibilities based on the requirements of the organization and/or your performance.

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