Utilization Management Nurse

Vŏlenz® Health is the platform to simplify healthcare – the destination for employers, payers, providers and members to reduce costs, improve quality, and elevate the healthcare experience. The Valenz mindset and culture of innovation combine to create a distinctly different approach to an inefficient, uninspired health system. With fully integrated solutions, Valenz engages early and often to execute across the entire patient journey – from care navigation and management to payment integrity, plan performance and provider verification. With a 99% client retention rate, we elevate expectations to a new level of efficiency, effectiveness and transparency where smarter, better, faster healthcare is possible. About This Opportunity: As a Utilization Management Nurse, you’ll oversee and manage the Utilization Management process to ensure the appropriate, necessary, and cost-effective delivery of healthcare services to plan participants. You will review UM activities, including prospective, concurrent, and retrospective reviews, and collaborate with our internal teams and healthcare professionals to ensure the delivery of high-quality care while minimizing unnecessary healthcare expenses. Things You’ll Do Here: Conduct timely reviews of UM activities, including prospective, concurrent, and retrospective reviews and apply to summary plan documents or other resources related to the request. Collaborate with appropriate parties to apply the correct UM criteria within the appropriate timelines. Promote quality care and cost-effective outcomes that enhance the physical, psychosocial, and vacation health of plan participants. Ensure compliance with regulatory standards and guidelines related to UM activities, such as those set forth by CMS, URAC, and other regulatory agencies. Identify and report cases of potential overutilization, underutilization, or improper utilization of healthcare services. Identify potential catastrophic, high-risk, and disease management cases and refer cases to the appropriate team. Communicate UM decisions and recommendations to healthcare providers and plan participants. Maintain accurate and complete records of UM activities and ensure confidentiality of sensitive information. Participate in ongoing UM education and training to stay up-to-date with industry developments. Maintain a high level of confidentiality in accordance with HIPAA. Maintain an active role in assuring continuity of care for all inpatients through early discharge planning. Identify and communicate to the Quality Improvement Coordinator potential quality of care and patient safety issues. Perform other duties as assigned Reasonable accommodation may be made to enable individuals with disabilities to perform essential duties. What You’ll Bring to the Team: 3+ years of clinical nursing experience. Active, Unrestricted RN License in your state of residence. Ability to work in a fast-paced, detailed, deadline-driven environment. Ability to maintain strict confidentiality and handle sensitive information with discretion. Experience working independently with strong problem solving and organization skills. Strong aptitude for relationship building with a highly effective communication style. A plus if you have: Utilization Management or Case Management Certification. Where You’ll Work: This is a fully remote position, and we’ll provide all the necessary equipment! Work Environment: You’ll need a quiet workspace that is free from distractions. Technology: Reliable internet connection—if you can use streaming services, you’re good to go! Security: Adherence to company security protocols, including the use of VPNs, secure passwords, and company-approved devices/software. Location: You must be US based, in a location where you can work effectively and comply with company policies such as HIPAA. Schedule This role follows a full time, Monday through Friday schedule during standard business hours. Below you’ll find the schedule according to your time zone. EST : 9:30am to 6pm CST : 8:30am to 5pm MST : 7:30am to 4pm PST : 6:30am to 3pm Why You’ll Love Working Here Valenz is proud to be recognized by Inc. 5000 as one of America’s fastest-growing private companies. Our team is committed to delivering on our promise to engage early and often for smarter, better, faster healthcare . With this commitment, you’ll find an engaged culture – one that stands strong, vigorous, and healthy in all we do. Benefits Generously subsidized company-sponsored Medical, Dental, and Vision insurance, with access to services through our own products, Healthcare Blue Book and KISx Card. Spending account options: HSA, FSA, and DCFSA 401K with company match and immediate vesting Flexible working environment Generous Paid Time Off to include vacation, sick leave, and paid holidays Employee Assistance Program that includes professional counseling, referrals, and additional services Paid maternity and paternity leave Pet insurance Employee discounts on phone plans, car rentals and computers Community giveback opportunities, including paid time off for philanthropic endeavors At Valenz, we celebrate, support, and thrive on inclusion, for the benefit of our associates, our partners, and our products. Valenz is committed to the principle of equal employment opportunity for all associates and to providing associates with a work environment free of discrimination and harassment. All employment decisions at Valenz are based on business needs, job requirements, and individual qualifications, without regard to race, color, religion or belief, national, social, or ethnic origin, sex (including pregnancy), age, physical, mental or sensory disability, HIV Status, sexual orientation, gender identity and/or expression, marital, civil union or domestic partnership status, past or present military service, family medical history or genetic information, family or parental status, or any other status protected by the laws or regulations in the locations where we operate. We will not tolerate discrimination or harassment based on any of these characteristics. #J-18808-Ljbffr