Remote Utilization Review Nurse

Summary

Join Sidecar Health as a Utilization Review Nurse and be at the forefront of evaluating medical necessity and quality of healthcare services for our members. You'll review medical records, ensure compliance with guidelines and policies, collaborate with providers, and participate in quality improvement initiatives.

Requirements

• Clinical credentials (RN)
• 5+ years of experience as a nurse providing care to patients, preferably in a hospital setting
• Medical billing and/or coding experience. This can be in a provider setting (billing, revenue cycle management, clinical auditing, legal compliance nurse) or payor setting (UM review, prior auth review, payment integrity, etc)
• Excellent written communication skills with experience drafting member, patient, and provider-facing letters
• Ability to think critically and make decisions with limited information
• Exceptional cross-functional collaboration skills with the ability to make recommendations to leadership
• Ability to problem solve and handle escalated cases
• Experience with Microsoft Suite
• Prior authorization experience (preferred)
• Bachelor's degree

Responsibilities

• Review and analyze medical records to assess the appropriateness and necessity of healthcare services
• Ensure compliance with established clinical guidelines, policies, and regulatory requirements
• Collaborate with healthcare providers to gather additional information when needed
• Utilize Milliman Care Guidelines (MCG) to evaluate the medical necessity and appropriateness of proposed and ongoing treatments
• Evaluate good faith estimates and “prebills” to determine scheduled care, including highlighting care that may not be included in the estimate (labs, radiology, pre-op visits, etc)
• Drafts letters to send to members outlining benefits and other considerations
• Collaborate with provider team and Member care team to evaluate care shopping options
• Participate in quality improvement initiatives to enhance the efficiency and effectiveness of the clinical review process
• Review claims reconsiderations and appeals, providing expert guidance to ensure accurate processing and resolution of issues coverage determination
• Assess claims for balance billing protections to ensure compliance with applicable regulations and internal policies

Benefits

• Competitive salary, bonus opportunity, and equity package
• Comprehensive Medical, Dental, and Vision benefits
• A 401k retirement plan
• Paid vacation and company holidays