Utilization Review Nurse

Summary

Join Sidecar Health, a company redefining health insurance, as a Utilization Review Nurse. You will play a crucial role in evaluating the medical necessity and quality of healthcare services for members, ensuring compliance with guidelines. Responsibilities include reviewing medical records, collaborating with providers, utilizing Milliman Care Guidelines (MCG), and drafting letters to members. This position requires clinical credentials (RN), 5+ years of nursing experience, medical billing/coding experience, and excellent communication skills. Sidecar Health offers a competitive salary, bonus opportunities, comprehensive benefits, and a chance to impact healthcare.

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
• 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
• Must reside in Ohio, Georgia, or Florida for consideration

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

Preferred Qualifications

• Prior authorization experience
• Bachelor's degree

Benefits

• Competitive salary, bonus opportunity, and equity package
• Comprehensive Medical, Dental, and Vision benefits
• A 401k retirement plan
• Paid vacation and company holidays
• Opportunity to make an impact at a rapidly growing mission-driven company transforming healthcare in the U.S