Utilization Review Nurse

Summary

Join Sidecar Health as a Utilization Review Nurse and play a vital role in ensuring members receive high-quality, medically necessary care. You will assess services and estimates, determining clinical appropriateness using guidelines like MCG. Responsibilities include reviewing medical records, drafting member-facing letters, collaborating with providers, and contributing to quality improvement. This role requires a Bachelor's degree, RN credentials, and significant experience in nursing and utilization review. The ideal candidate will possess strong communication, critical thinking, and problem-solving skills. Sidecar Health offers a market-based compensation approach with a salary range of $82,500-$95,000.

Requirements

• Bachelor's degree
• Clinical credentials (RN)
• 5+ years of experience as a nurse providing direct patient care, preferably in a hospital setting
• 3+ years of utilization review experience, preferably in a health plan, managed care, or third-party administrator environment
• Hands-on experience using Milliman Care Guidelines (MCG)
• Experience in medical billing and/or coding in one of the following
• Provider setting: billing, revenue cycle management, clinical auditing, legal compliance
• Payor setting: utilization management, prior authorization review, payment integrity
• Strong written communication skills, including drafting correspondence for members, patients, and providers
• Demonstrated ability to think critically and make sound decisions with limited information
• Proven cross-functional collaboration skills and experience presenting recommendations to leadership
• Strong problem-solving ability, especially in managing escalated or complex cases

Responsibilities

• Apply Milliman Care Guidelines (MCG) to assess medical necessity and appropriateness of treatments
• Review medical records, Good Faith Estimates, and prebills to evaluate scheduled care and identify potential gaps (e.g., labs, radiology, pre-op)
• Evaluate claims, reconsiderations, and appeals to support accurate coverage determinations and ensure compliance with balance billing protections
• Draft clear, member-facing letters outlining benefit decisions and relevant considerations
• Collaborate with providers, vendors and internal stakeholders to gather necessary clinical information for making coverage decisions
• Partner with Provider Engagement Team and Member Care teams to support care shopping and improve member experience
• Contribute to quality improvement initiatives that enhance clinical review processes
• Ensure adherence to clinical guidelines, internal policies, and regulatory requirements

Preferred Qualifications

Prior authorization experience