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 $80,000.00 /Yr. 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