Utilization Management Nurse

AssureCare is a privately held healthcare technology company that provides innovative care management solutions to commercial and health and human service providers. AssureCare’s flagship software platform, MedCompass, is used by healthcare providers throughout the United States to deliver end-to-end care management for millions of patients daily. MedCompass transforms healthcare management by automating processes and streamlining workflows, thus allowing care professionals to make better decisions that dramatically improve the quality of care and lower costs. AssureCare is considered an industry leader in developing, modular, seamless solutions designed to improve patient outcomes and reduce avoidable costs associated with population health management. AssureCare is a Vora Group company with headquarters in Cincinnati, OH. For more information, please visit https://www.assurecare.com/

Conduct reviews of medical records, treatment plans, and authorization requests to determine the medical necessity, appropriateness, and efficiency of healthcare services. Evaluate the clinical appropriateness of inpatient, outpatient, and other healthcare services in accordance with established guidelines and criteria. Collaborate with healthcare providers to discuss treatment plans, recommending alternatives when necessary to ensure the best possible care. Assist in the coordination of care for patients, ensuring that the treatment provided is medically necessary and delivered in the most appropriate setting. Participate in interdisciplinary team meetings to discuss complex cases and develop care plans that align with best practices. Ensure timely and accurate documentation of all utilization management decisions, maintaining confidentiality and compliance with HIPAA regulations. Utilize evidence-based clinical guidelines (such as InterQual, Milliman) to assess and determine medical necessity for various treatments and services. Work with healthcare providers to clarify requests and ensure they meet criteria for coverage and authorization. Serve as a liaison between healthcare providers, patients, insurance companies, and other stakeholders to facilitate the appropriate utilization of services. Communicate decisions effectively and explain the rationale for approvals, denials, and modifications of requested services. Provide education and guidance to healthcare providers and patients regarding utilization management policies and procedures. Ensure that utilization management practices comply with regulatory standards, accreditation requirements, and company policies. Assist with audits, quality improvement initiatives, and data collection efforts related to utilization management performance. Stay current on industry trends, healthcare regulations, and emerging clinical guidelines. Review and process appeal requests related to denials of service or coverage, working to resolve issues in a timely and thorough manner. Communicate with providers and insurance representatives to address denials and assist in resolving any disputes.