Contract Utilization Management Nurse (Healthcare)

TL;DR

Contract Utilization Management Nurse (Healthcare): Reviewing service utilization and guiding care decisions for PACE participants with an accent on medical necessity, regulatory compliance, and care transitions. Focus on conducting concurrent reviews of admissions, managing provider appeals, and optimizing value-based care delivery.

Location: Fully remote, must be based in the United States

Compensation: $42.00/Hour

Company

hirify.global is an end-to-end ecosystem providing purpose-built software solutions for PACE programs to improve care coordination, financial performance, and compliance for seniors.

What you will do

• Ensure participant care and claims are reasonable, necessary, and consistent with PCP coordination and medical standards.
• Conduct concurrent reviews of hospital and SNF admissions to drive efficient and timely transitions of care.
• Coordinate and review services from contracted providers to ensure alignment with care plans.
• Advocate for high-quality care and reduced hospital stays while maintaining accurate clinical records.
• Lead the provider appeals process and collaborate with Medical Directors to issue written determinations.

Requirements

• Current RN license.
• 3 to 5 years of utilization management experience.
• Proven experience working in risk-based integrated models of care.
• Must be based in the United States.
• This position is not eligible for sponsorship.
• Ability to use data to drive decisions and collaborate with internal/external stakeholders.

Culture & Benefits

• 1-year contract with the possibility of extension.
• Opportunity to be part of a trailblazing team in healthcare technology.
• Collaborative, inclusive, and dynamic work environment.