Job Description:
• Provide comprehensive care coordination services across the care continuum
• Prepare clinical reviews using clinical guidelines and present recommendations to physician reviewers for final determination
• Conduct prior authorization, concurrent, and retrospective utilization management reviews
• Support discharge planning, care coordination, clinical outcomes, and quality of care
• Monitor clinical quality concerns, identify outlier and long-length-of-stay cases, and escalate complex issues
• Interact with external facilities and providers to gather clinical information for medical necessity reviews and care plans
• Assist with coding, medical records/documentation, pre-certification, reimbursement, and claim denials/appeals
• Use active listening and motivational interviewing during member calls and document interactions
• Assess and facilitate appropriate clinical programs and discharge planning following discharge
• Manage departmental escalations through resolution and collaborate with the Medical Director on CM and UM cases
• Participate in virtual team huddles, supervisor one-to-ones, instant messaging, check-ins, and member/provider calls
Requirements:
• Must have a current, unrestricted Texas nursing license or Compact License; include license number(s) and corresponding state(s) in resume
• Diploma from an accredited school/college of nursing required
• 1-2 years of experience working at a health plan performing utilization management using standard practice guidelines
• 3-5 years of clinical experience in a hospital or ambulatory setting assisting with direct patient care
• Previous healthcare/managed care appeals experience
• Working knowledge of medical and insurance industry terminology, including basic CPT/ICD10, authorizations, digital health programs, and NCQA/URAC standards
• Experience outreaching and educating members telephonically
• Ability to work independently in a fast-paced, deadline-oriented, tech-savvy work environment
• Interest or experience in cardiology/pulmonology, women’s health, orthopedic surgery/physical medicine, primary care/pediatrics, or oncology
• Required dedicated, private work area and secure handling of sensitive documents
• High-speed internet connection/service
• Must reside in the United States in the CST or EST time zones
• Rotating on-call weekend availability for utilization review cases
Benefits:
• Comprehensive health, dental, and vision insurance as well as life and disability
• Retirement savings plan with company match
• Generous time off/vacation
• Professional development opportunities
• Flexible and remote work environment
• Competitive salary