Utilization Management Nurse III

At HMA, we believe in recognizing and celebrating the achievements of our dedicated staff. We offer flexibility to work schedules that support people in all time zones across the US, ensuring a healthy work-life balance. Employees have the option to work remotely or enjoy the amenities of our renovated office located just outside Seattle with free parking, gym, and a multitude of refreshments. Our performance management program is designed to elevate career growth opportunities, fostering a collaborative work culture where every team member can thrive. We also prioritize having fun together by hosting in person events throughout the year including an annual all hands, summer picnic, trivia night, and a holiday party.

What we are looking for: We are always searching for unique people to diversify our team. We only hire people that care deeply about others, thrive in evolving environments, gain satisfaction from being part of a team, are motivated by tackling complex challenges, are courageous enough to share ideas, action-oriented, resilient, and results-driven. What you can expect: You can expect an inclusive, flexible, and fun culture, comprehensive salary, pay transparency, benefits, and time off package with plenty of personal development and growth opportunities. If you are looking for meaningful work, a clear purpose, high standards, work/life balance, and the ability to contribute to something important, find out more about us at: https://www.accesshma.com/ How YOU will make a Difference: The Utilization Management Nurse collaborates with external entities such as Brokers, Group Contacts, and Stop Loss supports to provide updated information on case specifics within HIPAA regulations. The Utilization Management Nurse is responsible for efficient utilization of health services by providing monitoring of member utilization and claim patterns; and makes referrals to Case Manager nurses for ongoing case management for complex care.

Performs Utilization Management and applies first the terms of the SPD (Summary Plan Description), considering any benefit limitations/exclusions and PPO status of requesting provider/facility. Reviews are conducted using approved criteria for appropriateness of services, setting/level of care and length of stay. Provides ongoing review management of treatment progress as needed to provide personalized support and care coordination for complex, catastrophic or ongoing chronic medical conditions. Evaluates services requested to meet an individual’s health care needs, with the goal to provide personalized management to promote and ensure continuity of care coordination. Other duties as assigned