Sidecar Health - Utilization Review Nurse

Sidecar Health is redefining health insurance with the mission to make excellent healthcare affordable and attainable for everyone. We are seeking driven individuals to help us 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, join us!

About the Role

As a Utilization Review Nurse, you will play a critical role in ensuring our members receive high-quality, medically necessary care. You will assess upcoming services and Good Faith Estimates to determine clinical appropriateness, applying established guidelines like MCG to support coverage decisions. You will also draft clear, member-facing letters aligned with Sidecar Health policy, helping our members understand their benefits and options.

Must reside in Florida, Georgia, Kentucky, or Ohio for consideration.

Key Responsibilities

• Apply Milliman Care Guidelines (MCG) to assess medical necessity and appropriateness of treatments.
• Review medical records, Good Faith Estimates, and prebills to evaluate scheduled care and identify potential gaps (e.g., labs, radiology, pre-op).
• Evaluate claims, reconsiderations, and appeals to support accurate coverage determinations and ensure compliance with balance billing protections.
• Draft clear, member-facing letters outlining benefit decisions and relevant considerations.
• Collaborate with providers, vendors, and internal stakeholders to gather necessary clinical information for making coverage decisions.
• Partner with the Provider Engagement Team and Member Care teams to support care shopping and improve member experience.
• Contribute to quality improvement initiatives that enhance clinical review processes.
• Ensure adherence to clinical guidelines, internal policies, and regulatory requirements.

Role Requirements

• Bachelor's degree.
• Clinical credentials (RN).
• 5+ years of experience as a nurse providing direct patient care, preferably in a hospital setting.
• 3+ years of utilization review experience, preferably in a health plan, managed care, or third-party administrator environment.
• Hands-on experience using Milliman Care Guidelines (MCG).
• Experience in medical billing and/or coding in one of the following:
  • Provider setting: billing, revenue cycle management, clinical auditing, legal compliance.
  • Payor setting: utilization management, prior authorization review, payment integrity.
• Strong written communication skills, including drafting correspondence for members, patients, and providers.
• Demonstrated ability to think critically and make sound decisions with limited information.
• Proven cross-functional collaboration skills and experience presenting recommendations to leadership.
• Strong problem-solving ability, especially in managing escalated or complex cases.
• Prior authorization experience strongly preferred.

Compensation & Company Information

Sidecar Health adopts a market-based approach to compensation, where base pay varies depending on location and is further influenced by job-related skills and experience. The current expected salary range for this position is $82,500 - $95,000.

Sidecar Health is an Equal Opportunity employer committed to building a diverse team. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status.