Utilization Management Nurse

About Our Opportunity

As a Utilization Management Nurse, you will play a vital role in delivering comprehensive, patient-centered care by assessing individual needs, developing personalized care plans, and fostering collaboration among healthcare providers. Using your clinical knowledge, you will guide patients through the healthcare system, support adherence to treatment plans, and advocate for high-quality outcomes through education, emotional support, and clear communication. You will also contribute to wellness promotion, effective use of resources, and compliance with both regulatory and organizational standards.

• Conduct timely reviews of UM activities, including prospective, concurrent, and retrospective reviews and apply to summary plan documents or other resources related to the request.
• Collaborate with appropriate parties to apply the correct UM criteria within the appropriate timelines.
• Promote quality care and cost-effective outcomes that enhance the physical, psychosocial, and vacation health of plan participants.
• Ensure compliance with regulatory standards and guidelines related to UM activities, such as those set forth by CMS, URAC, and other regulatory agencies.
• Identify and report cases of potential over utilization, under utilization, or improper utilization of healthcare services.
• Identify potential catastrophic, high-risk, and disease management cases and refer cases to the appropriate team.
• Communicate UM decisions and recommendations to healthcare providers and plan participants.
• Maintain accurate and complete records of UM activities and ensure confidentiality of sensitive information.
• Participate in ongoing UM education and training to stay up-to-date with industry developments.
• Maintain a high level of confidentiality in accordance with HIPAA.
• Maintain an active role in assuring continuity of care for all inpatients through early discharge planning.
• Identify and communicate to the Quality Improvement Coordinator potential quality of care and patient safety issues.
• Perform other duties as assigned.

Reasonable accommodation may be made to enable individuals with disabilities to perform essential duties.

• Three (3) or more years of clinical nursing experience.
• One (1) or more years of UM experience.
• Active, Unrestricted RN License in your state of residence.
• Ability to work in a fast-paced, detailed, deadline-driven environment.
• Ability to maintain strict confidentiality and handle sensitive information with discretion.
• Experience working independently with strong problem solving and organization skills.
• Strong aptitude for relationship building with a highly effective communication style.

A plus if you have:

• Utilization Management or Case Management Certification.

This is a fully remote position, and we’ll provide all the necessary equipment!

• Work Environment: You’ll need a quiet workspace that is free from distractions.
• Technology: Reliable internet connection—if you can use streaming services, you’re good to go!
• Security: Adherence to company security protocols, including the use of VPNs, secure passwords, and company-approved devices/software.
• Location: You must be US based, in a location where you can work effectively and comply with company policies such as HIPAA.

Valenz is proud to be recognized by Inc. 5000 as one of America’s fastest-growing private companies. Our team is committed to delivering on our promise to engage early and often for smarter, better, faster healthcare. With this commitment, you’ll find an engaged culture – one that stands strong, vigorous, and healthy in all we do.

• Generously subsidized company-sponsored Medical, Dental, and Vision insurance, with access to services through our own products, Healthcare Blue Book and KISx Card.
• Spending account options: HSA, FSA, and DCFSA
• 401K with company match and immediate vesting
• Flexible working environment
• Generous Paid Time Off to include vacation, sick leave, and paid holidays
• Employee Assistance Program that includes professional counseling, referrals, and additional services
• Paid maternity and paternity leave
• Pet insurance
• Employee…