Utilization Review Nurse

Position Overview

• Location Type: Onsite (Must reside in Florida, Georgia, Kentucky, or Ohio for consideration)
• Employment Type: Full-time
• Salary: Not specified

Sidecar Health is redefining health insurance with a mission to make excellent healthcare affordable and attainable for everyone. As a Utilization Review Nurse at Sidecar Health, you'll play a crucial role in evaluating the medical necessity and quality of healthcare services for members, ensuring adherence to established guidelines. You will also be responsible for reviewing upcoming services and good faith estimates for members and writing letters based on the Sidecar Health policy.

Requirements

• Clinical Credentials: Registered Nurse (RN)
• Experience: 5+ years of experience as a nurse providing care to patients, preferably in a hospital setting.
• Medical Billing/Coding Experience: Experience in medical billing and/or coding (provider or payor setting)

Responsibilities

• Utilize Milliman Care Guidelines (MCG) to evaluate the medical necessity and appropriateness of proposed and ongoing treatments for members.
• Participate in quality improvement initiatives to enhance the efficiency and effectiveness of the clinical review process.
• Ensure compliance with established clinical guidelines, policies, and regulatory requirements.
• Review and analyze medical records to assess the appropriateness and necessity of healthcare services.
• Evaluate good faith estimates and “prebills” to determine scheduled care, highlighting care that may not be included in the estimate (labs, radiology, pre-op visits, etc.).
• Collaborate with healthcare providers to gather additional information when needed.
• Drafts letters to send to members outlining benefits and other considerations.
• Collaborate with provider team and Member care team to evaluate care shopping options.
• Review claims reconsiderations and appeals, providing expert guidance to ensure accurate processing and resolution of coverage determination issues.
• Assess claims for balance billing protections to ensure compliance with applicable regulations and internal policies.

Company Information

Sidecar Health is redefining health insurance. Our mission is to make excellent healthcare affordable and attainable for everyone. We know that to accomplish this lofty mission, we need driven people who will make things happen. The passionate people who make up Sidecar Health’s team come from all over, with backgrounds as tech leaders, policy makers, healthcare professionals, and beyond. And they all have one thing in common—the desire to fix a broken system and make it more personalized, affordable, and transparent. If you want to use your talents to transform healthcare in the United States, come join us!

Application Instructions

• Location Requirement: Must reside in Florida, Georgia, Kentucky, or Ohio for consideration.