Utilization Management Registered Nurse
Cedar is a new, passionate organization founded by top-tier entrepreneurs who are committed to transforming our healthcare system! Cedar is building a ground-breaking technology platform that eliminates unnecessary administration from the billing and payments process, enabling providers to get paid faster and patients to get care more easily and quickly. Founded in 2017 with substantial financial backing, we are a hard-working, thriving team looking for dedicated teammates to make a major impact on the healthcare system. We are committed to living what we value to provide a positive and dynamic working environment for our team members. Based on the principle of Colonel John Boyd’s OODA Loop, we know we must move quickly and with purpose to effect meaningful change in healthcare.
We are looking for a passionate Registered Nurse with a deep understanding of prior authorizations to contribute to our authorization automation product. The successful applicant will be responsible for handling referral/authorization and utilization management activities, suggest potential improvements and/or changes as appropriate, and handle and disposition the Prior Authorization (PA) as may be assigned. This role will also perform day-to-day activities required for PA processing and follow defined business rules and policies, including timeliness requirements. This person ensures their assigned areas are aligned with referral/authorization management policies, procedures, and processes to maintain strict contract requirements and to promote the delivery of high-quality, efficient care. This person collects and analyzes individual data to resolve operational efficiency and effectiveness, and provides feedback, and actively engages with our product teams. In addition, the UM Nurse ensures timely and accurate processing of referrals and authorizations including benefit/medical necessity review, pre-authorization, inpatient current review, discharge planning, and assessment for potential quality issues.
Additionally, you will review prior authorization requests for appropriate care and setting, following guidelines and policies, and approve services or forward requests to the appropriate Physician or Medical Director with recommendations for other determinations.
This role is required to be located in the United States.
Responsibilities:
- Complete medical necessity and level of care reviews for requested services using clinical judgment and refer to Medical Directors for review depending on case findings
- Collaborate with various staff within provider networks and case management teams electronically or telephonically to coordinate member care
- Educate providers on utilization and medical management processes
- Provide clinical knowledge and act as a clinical resource to non-clinical team staff.
- Enter and maintain pertinent clinical information in various medical management systems
Requirements:
- Solid understanding of peer review criteria, NCQA, CMS, and other regulatory and accreditation requirements
- Has done medical record reviews before and used software to enter their findings
- Hold an active LPN or RN state license.
- Strong understanding of payer medical policies
- Experience reading clinical documentation to identify/extract service requirements, such as age, comorbidities, medical history, etc.
- Understanding of the Utilization Management process
- Excellent digital literacy, including the ability to quickly learn multiple web and desktop-based tools. The end-user experience on these tools will change frequently- candidates will be encouraged to adapt quickly while maintaining high quality and through out standards