Utilization Review RN

Who We Are

UST Health Proof is a trusted partner for health plans, offering an integrated ecosystem for health plan operations. Our BPaaS solutions manage complex admin tasks, allowing our customers to prioritize members’ well-being. With our commitment to simplicity, honesty, and leadership, we navigate challenges with our customers to achieve affordable health care for all.

Utilization Review RN – Lead II – BPM

As a Utilization Review RN, you will perform prospective, concurrent and retrospective review of inpatient, outpatient, ambulatory and ancillary services to ensure medical necessity, appropriate length of stay, intensity of service and level of care, including appeal requests initiated by providers, facilities and members.

• Review, research and authorize requests for elective, direct, ancillary, urgent, emergency and other services.
• Analyze, research, respond to and prepare documentation related to retrospective review requests and appeals in accordance with local, state and federal regulatory and designated accreditation (e.g. NCQA) standards.
• Establish, coordinate, and communicate discharge planning needs with appropriate internal and external entities.
• Analyze patterns of care associated with disease progression; identify contractual services and organize delivery through appropriate channels.
• Research and resolve issues related to benefits, member eligibility, non-elective and non-authorized services, coordination of benefits, care coordination, etc.
• Identify and document quality of care issues; resolve or route to appropriate area for resolution.

• Registered Nurse with current unrestricted Registered Nurse license required.
• Certification in Case Management may be preferred based upon designated department assignment.
• Minimum of 2 years’ clinical experience which may include acute patient care, discharge planning, case management, and utilization review.
• Demonstrated clinical knowledge and experience relative to patient care and health care delivery processes.
• Minimum 1 year health insurance plan experience or managed care environment preferred.
• Excellent written and verbal communication skills. Excellent customer service and interpersonal skills.
• Working knowledge of current industry Microsoft Office Suite PC applications.
• Ability to apply clinical criteria/guidelines for medical necessity, setting/level of care and concurrent patient management.

Remote – $65,000‑$85,000

Full-time, regular employees accrue up to 16 days of paid vacation per year, 6 days of paid sick leave, 10 paid holidays, and bereavement leave. Eligible for 401(k) with employer matching, medical/dental/vision insurance, life and disability insurance, short- and long-term disability benefits, and additional voluntary short-term disability benefits.

UST Health Proof is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, and other protected characteristics.