Utilization Nurse

Guidehealth is a data-powered, performance-driven healthcare company dedicated to operational excellence. Our goal is to make great healthcare affordable, improve the health of patients, and restore the fulfillment of practicing medicine for providers. Driven by empathy and powered by AI and predictive analytics, Guidehealth leverages remotely-embedded Healthguides™ and a centralized Managed Service Organization to build stronger connections with patients and providers. Physician-led, Guidehealth empowers our partners to deliver high-quality healthcare focused on outcomes and value inside and outside the exam room for all patients. BENEFITS: While you are hard at work advancing value-based healthcare, we are here to ensure YOU have the care you and your family need and the opportunities for growth and development. Our commitments to you include: Work from Home: Guidehealth is a fully remote company, providing you the flexibility to spend less time commuting and more time focusing on your professional goals and personal needs. Keep Health a Priority: We offer comprehensive Medical, Dental, and Vision plans to keep you covered. Plan for the Future: Our 401(k) plan includes a 3% employer match to your 6% contribution. Have Peace of Mind: We provide Life and Disability insurance for those "just in case" moments. Additionally, we offer voluntary Life options to keep you and your loved ones protected. Feel Supported When You Need It Most: Our Employee Assistance Program (EAP) is here to help you through tough times. Take Time for Yourself: We offer Flexible Time Off tailored to meet your needs and the needs of the business, helping you achieve work-life balance and meet your personal goals. Support Your New Family: Welcoming a new family member takes time and commitment. Guidehealth offers paid parental leave to give you the time you need. Learn and Grow: Your professional growth is important to us. Guidehealth offers various resources dedicated to your learning and development to advance your career with us.

Performing utilization review services in compliance with federal and state regulations, and the URAC standards for client members seeking healthcare treatment and services. Obtaining, analyze and document all supporting clinical within the documentation record. Completing a timely review of health care services utilizing and documenting the appropriate medical criteria used to make a clinical determination. Completing timely written and / or verbal communication of pre-certifications and concurrent review determinations for healthcare services to all parties required by regulations, URAC standards and Guidehealth policies. Communicating with the Medical Director and Peer Reviewer(s) for cases requiring review of medical necessity, appropriate treatment, intensity/ number of inpatient and outpatient treatment or quality of care issues. Interfacing with ordering providers and provider organizations on a routine basis. In some instances, communication with members or their representatives may be appropriate. Initiating the referral of targeted patients into organized disease management programs to assist with continuity and quality of care. Managing and documenting after-hours phone calls from members and providers on a rotational basis Maintaining confidentiality of member information, case records and file entries Participating in quality management activities Responsible for sending client specific benefit exhaustion letters upon request. Assisting with coordination and the design and development of clinical and client specific reports. May assist in the development of materials and packets for the QM/ UM Committee meetings, the documentation of minutes, preparation of spreadsheets, data collection and analysis, and follow-up tasks. Maintaining current knowledge and comply with regulatory requirements for multiple jurisdictions and medical groups Integrating ongoing, accurate knowledge of medical group guidelines and URAC standards into daily duties Responsible for continued professional growth and education that reflects knowledge and understanding of current nursing care practice as outlined in the Illinois Nurse Practice Act. Interacting with the IT Department for technical support related to computer systems, upgrades and other data