Registered Nurse (RN) - Manager
Sonder Health Plans
Atlanta, GA

Utilization Management Nurse

Sonder Health Plans Atlanta, GA Full-time Hybrid At Sonder Health Plans, we believe the healthcare system should be accessible, transparent, and easy to navigate. As a full-stack, technology-driven health plan, we are creating a customer-centric experience that gets our members the care they need when they need it. If you want to be part of the future of healthcare, we'd love for you to join us. Sonder Health Plans is looking for a full-time Utilization Management Nurse to make sure our health services are administered efficiently and effectively. The main goal of this position is to provide operational support and clinical expertise in the areas of health care services, member benefits and clinical operations for all of Sonder Health Plans members to improve member and provider satisfaction as well as the quality of care and health outcomes for members. Primary Responsibilities: Determine the appropriateness of inpatient and outpatient services following the evaluation of medical guidelines and benefit determinations Identify and report any quality of care concerns that occur while members are in acute care and/or skilled nursing facilities. Support Sonder Health Plans compliance to regulatory accreditation requirements for both state and federal agencies Support quality audits, chart audits and reviews of medical records as needed for either complex high cost cases or cases with quality of care issues Coordinate case management on complex cases that require additional clinical management support Conducts initial review of prior authorization or pre-certification requests for determination of coverage for members covered by sponsored health benefit plans Makes determinations based on medical necessity of plan-covered services based on internal policies reviewed and approved by the Chief Medical Officer of the plan Where appropriate, involves the Chief Medical Officer if a partial or fully adverse medical necessity determination is expected based on the initial review Works collaboratively with the Director of Health Services to achieve all UM targets on a monthly basis Participates in and supports all medical management initiatives including, but not limited to: ER visits, readmissions, OOA utilization and identification of potential high cost cases Collaborates with care managers on care transitions for patients with an emphasis on high risk patients at risk for readmission, on an as needed basis Responsible for planning and monitoring departmental activities and needs, collection and analysis of performance data, and performance management of Managers and other staff reporting to this position. Responsible for meeting staffing needs, vendor oversight, associate development, and performance assessment of all direct and indirect reports.??????? * Perform additional duties as requested. Required Qualifications: ADN, BSN, or Diploma nursing degree Minimum two (2) years of experience in case management and/or denials/appeals Minimum five (3 -5) years of experience working in a managed care environment with Medicare Advantage/Commercial populations, utilization management experience and acute clinical nursing experience Active Georgia Registered Nursing license Pre-authorization and Concurrent review experience Medical record investigative review knowledge. Proficient computer skills (ie. Word, Outlook, Excel, etc.) and utilizing the internet Strong professional communication with an acceptable use of English both (verbally and in writing) Ability to work independently with limited supervision Capable of working with people of diverse backgrounds Demonstrates adaptability and openness to alternative solutions and flexibility when interacting with internally with the team and externally with members Excellent customer service skills and great telephone etiquette Preferred Qualifications: Commercial or managed care payer background (Preferred) ACM, CCM, CPUR, CPUM, IQCI (Preferred) Equal Employment Opportunity Sonder Health Plans is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information. Sponsorship in US Must be eligible to work in the U.S. without Sponsorship Why You Should Join Us: You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role Work in a positive, start-up environment with limitless career growth Employer-sponsored medical, dental, vision and other supplemental benefit 401(k) plan Business Casual Dress Code Job Type: Full-time