Utilization Review Nurse - Remote

Overview

As a Utilization Review Nurse at Sidecar Health, you will evaluate the medical necessity and quality of healthcare services for members, ensuring adherence to established guidelines.

In Short

• Utilize Milliman Care Guidelines (MCG) for treatment evaluations.
• Participate in quality improvement initiatives.
• Ensure compliance with clinical guidelines and regulations.
• Review medical records for appropriateness of services.
• Analyze good faith estimates for scheduled care.
• Collaborate with healthcare providers for additional information.
• Draft letters outlining benefits for members.
• Evaluate care shopping options with teams.
• Review claims for coverage determination.
• Assess claims for balance billing protections.

Requirements

• Clinical credentials (RN).
• 5+ years of nursing experience.
• Experience in medical billing or coding.
• Excellent written communication skills.
• Critical thinking and decision-making abilities.
• Cross-functional collaboration skills.
• Problem-solving skills for escalated cases.
• Experience with Microsoft Suite.
• Prior authorization experience (preferred).
• Bachelor's degree.

Benefits

• Competitive salary, bonus opportunity, and equity package.
• Comprehensive Medical, Dental, and Vision benefits.
• A 401k retirement plan.
• Paid vacation and company holidays.
• Opportunity to impact a mission-driven company.