Role Description
Utilization Management QA RN
Lead II – BPM
Who We Are
UST HealthProof is a trusted partner for health plans, offering an integrated ecosystem for health plan operations. Our BPaaS solutions manage complex admin tasks, allowing our customers to prioritize members’ well-being. With our commitment to simplicity, honesty, and leadership, we navigate challenges with our customers to achieve affordable health care for all.
We have a strong global presence and a dedicated workforce of over 4000 people spread across the world.
Our brand is built on the strong foundation of simplicity, integrity, people-centricity, and leadership. We stay inspired in our goal to unburden healthcare and ensure it reaches all, equitably and effectively.
You Are
The Utilization Management QA RN is responsible for providing clinical and educational support assessments, analysis and coordination of the quality management program and assisting in the divisional accreditation process.
The Opportunity
- Responsible for training UM clinical staff on processes, policies, and systems.
- Participate & lead in the development, implementation, and updating of training manuals to reflect new approaches to training, departmental and/or system process changes and MCG criteria updates as needed.
- Oversee and mentor new employees during the initial training program.
- Work closely with the leadership team, QA, and subject matter experts external and internal to assess the learning environment and determine relevant resources for training.
- Educate staff in the clinical policies criteria and procedures of MCG as well as an overview of the department, general functions, responsibilities and department relationships with other departments.
This position description identifies the responsibilities and tasks typically associated with the performance of the position. Other relevant essential functions may be required.
What You Need
- Nursing Diploma or Associates Degree in Nursing required.
- Bachelors in nursing (BSN) or related fields preferred.
- Registered Nurse with current unrestricted Registered Nurse license in any of the 50 US states required.
- MCG certification preferred.
- 5 years’ experience in health related fields required.
- 3 years' experience with UM, Appeals & Grievances, Claims, QA, CMS & MCG guidelines.
- Proficient in relevant PC applications (Share point, Care Advance, NASCO, 3270, MCMS/AMP, CCDB, IKA and Portico system)
- Basic knowledge of ICD9/ICD 10 and CPT Codes
- MEDCO,Member Health Record, VDA (Virtual Desk Top), Care Advance
- Knowledge of local, state and federal regulations (PA250, PA350, DOL, ERISA, HIPPA)
- Leadership experience
- Ability to use clinical assessments and interventions
- Knowledge of effective communication techniques and theories
Compensation can differ depending on factors including but not limited to the specific office location, role, skill set, education, and level of experience. UST HealthProof provides a reasonable range of compensation for roles that may be hired in various U.S. markets as set forth below.
Role Location: Remote
Compensation Range: $65,000-$85,000
Benefits
Full-time, regular employees accrue up to 16 days of paid vacation per year, receive 6 days of paid sick leave each year (pro-rated for new hires throughout the year), 10 paid holidays, and are eligible for paid bereavement leave. They are eligible to participate in the Company’s 401(k) Retirement Plan with employer matching. They and their dependents residing in the US are eligible for medical, dental, and vision insurance, as well as the following Company-paid benefits: basic life insurance, accidental death and disability insurance, and short- and long-term disability benefits. Regular employees may purchase additional voluntary short-term disability benefits, and participate in a Health Savings Account (HSA) as well as a Flexible Spending Account (FSA) for healthcare, dependent child care, and/or commuting expenses. Certain regular employees may have the potential for quarterly incentive-based bonuses and or commissions depending on role. Benefits offerings vary in Puerto Rico.
Part-time employees receive 6 days of paid sick leave each year (pro-rated for new hires throughout the year) and are eligible to participate in the Company’s 401(k) Retirement Plan with employer matching.
Full-time temporary employees receive 6 days of paid sick leave each year (pro-rated for new hires throughout the year) and are eligible to participate in the Company’s 401(k) program with employer matching. They and their dependents residing in the US are eligible for medical, dental, and vision insurance.
Part-time temporary employees receive 6 days of paid sick leave each year (pro-rated for new hires throughout the year).
All US employees who work in a state or locality with more generous paid sick leave benefits than specified here will receive the benefit of those sick leave laws.
What We Believe
At UST HealthProof, we envision a bold future for American healthcare. Our values are the bedrock beliefs our organization holds dear. They not only define what our brand stands for but also serve as a compass guiding every action and decision.
Guiding Principles
These principles illuminate the path of ‘how’ we operate. They detail actions and behaviors we much embody to honor our values and achieve our goals.
Simplifying complexity underlines everything we do—this approach is what makes us unique. We come with an open mind and straightforward approach, cutting our way to the core with measurable and actionable insights.
Integrity is our currency to build relationships. We believe in being open and honest. It is only natural when we have nothing to hide. It demonstrates that we are here to do the right thing, no matter who is watching.
Everything that we do reflects our deep bonds with peers and customers. These aren't mere transactions, but transformational ties. They shape our culture and decisions, affirming that our true value lies in the lives we touch and impact.
Taking ownership is about taking initiative, being in-charge and driving things to completion. It’s a brave choice to ‘own’ all aspects of our work, ensuring we take full responsibility for everything we handle.
Mission
A future possible only when health plans are free from administrative burdens so they can truly focus on what matters more – their members’ well-being.
Equal Employment Opportunity Statement
UST HealthProof is an Equal Opportunity Employer.
All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other applicable characteristics protected by law. We will consider qualified applicants with arrest or conviction records in accordance with state and local laws and “fair chance” ordinances.
UST HealthProof reserves the right to periodically redefine your roles and responsibilities based on the requirements of the organization and/or your performance.
#Healthproof
#CB
Skills
utilization management,healthcare,quality assurance,auditing,data management,documentation,
