Utilization Management Nurse

Vālenz® Health is the platform to simplify healthcare – the destination for employers, payers, providers and members to reduce costs, improve quality, and elevate the healthcare experience. The Valenz mindset and culture of innovation combine to create a distinctly different approach to an inefficient, uninspired health system. With fully integrated solutions, Valenz engages early and often to execute across the entire patient journey – from care navigation and management to payment integrity, plan performance and provider verification. With a 99% client retention rate, we elevate expectations to a new level of efficiency, effectiveness and transparency where smarter, better, faster healthcare is possible.

As a Utilization Management Nurse, you will play a vital role in delivering comprehensive, patient-centered care by assessing individual needs, developing personalized care plans, and fostering collaboration among healthcare providers. Using your clinical knowledge, you will guide patients through the healthcare system, support adherence to treatment plans, and advocate for high-quality outcomes through education, emotional support, and clear communication. You will also contribute to wellness promotion, effective use of resources, and compliance with both regulatory and organizational standards. Where You’ll Work: This is a fully remote position, and we’ll provide all the necessary equipment! Work Environment: You’ll need a quiet workspace that is free from distractions. Technology: Reliable internet connection—if you can use streaming services, you’re good to go! Security: Adherence to company security protocols, including the use of VPNs, secure passwords, and company-approved devices/software. Location: You must be US based, in a location where you can work effectively and comply with company policies such as HIPAA.

Conduct timely reviews of UM activities, including prospective, concurrent, and retrospective reviews and apply to summary plan documents or other resources related to the request. Collaborate with appropriate parties to apply the correct UM criteria within the appropriate timelines. Promote quality care and cost-effective outcomes that enhance the physical, psychosocial, and vacation health of plan participants. Ensure compliance with regulatory standards and guidelines related to UM activities, such as those set forth by CMS, URAC, and other regulatory agencies. Identify and report cases of potential overutilization, underutilization, or improper utilization of healthcare services. Identify potential catastrophic, high-risk, and disease management cases and refer cases to the appropriate team. Communicate UM decisions and recommendations to healthcare providers and plan participants. Maintain accurate and complete records of UM activities and ensure confidentiality of sensitive information. Participate in ongoing UM education and training to stay up-to-date with industry developments. Maintain a high level of confidentiality in accordance with HIPAA. Maintain an active role in assuring continuity of care for all inpatients through early discharge planning. Identify and communicate to the Quality Improvement Coordinator potential quality of care and patient safety issues. Perform other duties as assigned.