Behavioral Health - Utilization Review RN

UST HealthProof 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. We have a strong global presence and a dedicated workforce of over 4000 people spread across the world. Our brand is built on the strong foundation of simplicity, integrity, people-centricity, and leadership. We stay inspired in our goal to unburden healthcare and ensure it reaches all, equitably and effectively.

UST HealthProof is searching for a highly motivated behavioral Health - Utilization Review RN to join our team. As a Behavioral Health - Utilization Review RN, you will administer telephonic coordination and delivery of clinical behavioral health services designed to meet the wellness and recovery needs of the consumer.

Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members. Review, research and authorize requests for authorization of elective, direct, ancillary, urgent, emergency, etc. services. Contact appropriate medical and support personnel to identify and recommend alternative treatment, service levels, length of stays, etc. using approved clinical protocols. 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. Research and resolve issues related to benefits, member eligibility, non-elective and non-authorized services, coordination of benefits, care coordination, etc. This position description identifies the responsibilities and tasks typically associated with the performance of the position. Other relevant essential functions may be required.