Pre-Certification/Utilization Management Nurse

First Stop Health provides care that people love® with our convenient, high-quality, and confidential virtual care solutions – Telemedicine, Virtual Mental Health, and Virtual Primary Care. We help our patients save time and money through compassionate care that’s available 24/7 via app, website, or phone. First Stop Health offers a comprehensive benefits package that includes various health and medical coverage options, dental and vision coverage, disability, and life coverage, making healthcare easily accessible. For those that choose to waive medical coverage a monthly medical waiver allowance will be provided. First Stop Health offers a remote-first work environment and flexible paid time off, including Summer Fridays. Furthermore, the employer match 401k plan and monthly phone stipend demonstrate the company's commitment to employee financial well-being. The First Stop Health membership benefit is another added perk for employees and provides Virtual Urgent Care, Virtual Mental Health, and Virtual Primary Care from their very first day!

The Utilization Management (UM) Clinician is a registered nurse responsible for conducting utilization and quality management activities for First Stop Health in accordance with Utilization Management policies and procedures. The position responsibilities include the management of medical costs through timely prospective, concurrent, and retrospective review activities. The UM Nurse is responsible for conducting clinical reviews and authorizing services based on established medical necessity criteria and benefit guidelines. Working independently, the UM Nurse evaluates inpatient and outpatient service requests to determine appropriateness and medical necessity using clinical judgment and standardized tools such as InterQual or MCG. The UM Nurse collaborates closely with Intake Coordinators, Case Managers, and provider offices to ensure timely determinations and seamless care coordination. This role requires strong attention to detail, working knowledge of CPT/HCPCS and ICD-10 codes, and the ability to manage multiple reviews while maintaining compliance with all regulatory and contractual requirements.

Contributes to UM program goals and objectives in containing health care costs and maintaining a high-quality medical delivery system through the ongoing development and refinement of program procedures for conducting UM activities. Apply clinical guidelines (e.g., InterQual, MCG) to support decision-making for prior authorizations Maintain compliance with regulatory requirements, including NCQA, URAC, and HIPAA. Performs telephonic review for inpatient and outpatient services using First Stop Health approved medical review healthcare criteria and behavioral health criteria. Collects only pertinent clinical information and documents all UM review information using the appropriate software system. Identify and refer complex cases to Case Management or Medical Director when appropriate Promotes alternative care programs and research available options including costs and appropriateness of patient placement in collaboration with health plan clients. Communicates directly with physician providers/designees when appropriate to gather all clinical information to determine the medical necessity of requested healthcare services. Communicates directly with the designated medical director/physician advisor regarding all inpatient cases and outpatient/ambulatory requests for health care services that do not meet medical necessity or appropriate level of care and out of network transfer issues. Recommends, coordinates, and educates providers regarding alternative care options. Maintains an active role in assuring the continuity of care for all inpatients through early discharge planning and working with hospital and health plan client discharge planners and social workers in the early identification of potential home care candidates or less restrictive level of care placement. Works collaboratively if Case Management is involved with member. Participates in UM program CQI (Continuous Quality Improvement) activities. Communicates all UM review outcomes in accordance with the health plan’s requirements. Follows relevant client time frame standards for conducting and communicating UM review determination. Maintains and submits reports and logs on review activities as outlined by the UM program operational procedures when directed. Identifies and communicates to the appropriate supervisory personnel all hospital, ancillary provider, physician provider and physician office concerns and issues. Identifies and communicates to the appropriate supervisory personnel all potential quality of care concerns and patient safety. Serves as liaison for provider staff and the health plan client. Maintains courteous, professional attitude when working with internal staff, hospital and physician providers, and health plan client. Identifies and communicates to health plan client and/or contracted ancillary providers all catastrophic and high-risk cases for case management referral. Actively participates in team and First Stop Health company meetings; and Performs other duties as requested by the appropriate supervisory personnel. Customer Services - Internal: Supports a positive working environment. Identifies and resolves potential personnel/peer problems and issues proactively, readily utilizing appropriate supervisors and team members as resources. Communicates to the appropriate supervisory personnel all problems, issues and/or concerns as they arise. Communicates to the appropriate supervisory personnel any issues or concerns related to quality of care. Maintains a courteous and professional attitude when working with all First Stop Health staff members and the management team. Readily available to non-clinical staff to answer questions and ensure that non-clinical administrative staff is performing within the scope of the non-clinical role. Actively participates in team meetings, as designated. Customer Services – External: Timely identifies and communicates to applicable practitioners, providers, and the health plan/client staff all issues and concerns related to the case at hand. Communicates to the client/health plan staff any issues or concerns related to quality of care, using First Stop Health policies/procedures. Works, communicates, and collaborates in harmony and in a courteous and professional manner with the patient, practitioner, provider, and multidisciplinary health care team members all issues, concerns and/or as the UM Plan is revised and/or new services are implemented/terminated. Serves as a liaison and patient advocate when deemed applicable for quality of care and cost outcomes; and Communicates appropriately and according to policy, and/or regulatory requirements with the practitioner(s), provider(s), patient/patient’s legally appointed representative any UM coverage determination(s).