A Life-Changing Company
At Sonder Health Plans, we believe the healthcare system should be accessible, transparent, and easy to navigate. As a full-stack, technology-driven health plan, we are creating a customer-centric experience that gets our members the care they need when they need it. If you want to be part of the future of healthcare, we’d love for you to join us.
Sonder Health Plans is looking for a full-time Utilization Review Nurse to make sure our health services are administered efficiently and effectively. The main goal of this position is to provide operational support and clinical expertise in the areas of health care services, member benefits and clinical operations for all of Sonder Health Plans members to improve member and provider satisfaction as well as the quality of care and health outcomes for members.
Reports to: Manager Medical Care Management
Description:
The Utilization management nurse’s role is to ensure that health care services are administered with quality, cost efficiency,
and within compliance. By continuously reviewing and auditing member treatment records, the utilization nurse will ensure that
members do not receive unnecessary procedures, ineffective treatment, or unnecessarily extensive hospital stays.
Responsibilities:
Some of the major role components include:
- Concurrent review of member’s clinical information for efficiency
- Ongoing review of precertification requests for medical necessity
- Coordinates member’s discharge planning needs with the healthcare team
- Employ effective use of knowledge, critical thinking, and skills to:
- Advocate quality care and enhanced quality of life
- Prevent member complications during hospital stay
- Advocate decreased hospital stay when appropriate
- Maintain accurate records of all member related interactions
- Prepare monthly member management and cost savings report
- Maintain monthly data regarding utilization of services.
- Work in an intensive, fast-paced environment with minimal supervision
- Ability to stay organized and interact well with others in any situation
- Provide daily updates to Manager of Utilization Management for review
- Other duties as assigned.
Qualifications:
- Strong interpersonal and communication skills and the ability to work effectively with a wide range of constituencies in a diverse community.
- Records maintenance skills.
- Ability to gather data, compile information, and prepare reports.
- Ability to plan, implement, and evaluate individual member care programs.
- Knowledge of medical billing procedures.
- Ability to communicate medical information to health care professionals and the public over the telephone under crisis circumstances.
- Advanced knowledge and proficiency of Microsoft Excel preferred
- Intermediate skills in Microsoft office suite and google.
- Ability to stay organized, manage multiple tasks, and prioritize accordingly.
- Effective communications skills, both written and verbal
- Ability to manage a large workload and thrive in a results-driven, fast-paced environment.
- Effective research, analytical, decision making, and critical thinking skills.
- Strong initiative and self-discipline when working independently.
- Familiar with Medicare Managed Care and applicable regulations.
- Commitment to maintain working knowledge and compliance with departmental policies & procedures, CMS requirements, NCQA, AAHC, as well as Federal & State guidelines, as applicable.
- Ability to practice ethics in daily operations, demonstrating professionalism and commitment to success, inspiring others towards high-level of engagement and teamwork.
- Ability to generate and maintain databases and/or spreadsheets for reporting, and initiatives.
- Comfortable learning and using digital tools.
- Βachelor’s degree in Nursing
- Active GA RN license or licensure in a compact state
- Minimum of 2 years prior experience in Utilization Management
Working Conditions:
- No or very limited physical effort required.
- Work environment involves minimal exposure to physical risks, such as operating dangerous equipment or working with chemicals.
- Work is normally performed in a typical interior/office work environment.
