Valenz® Health simplifies the complexities of self-insurance for employers through a steadfast commitment to data transparency and decision enablement powered by its Healthcare Ecosystem Optimization Platform. Offering a strong foundation with deep roots in clinical and member advocacy, alongside decades of expertise in claim reimbursement and payment validity, integrity, and accuracy, as well as a suite of risk affinity solutions, Valenz optimizes healthcare for the provider, payer, plan, and member. By establishing “true transparency” and offering data-driven solutions that improve cost, quality, and outcomes for employers and their members, Valenz engages early and often for smarter, better, faster healthcare.

About Our Opportunity

As a Utilization Management Supervisor within our Care Team, you will oversee the utilization management program and ensure that all processes and procedures are compliant with regulatory and accreditation standards. You’ll supervise our staff of Utilization Review Nurses, confirming all pre-authorization review meets expectations in both accuracy and within communicated deadlines. You’ll also manage a reduced workload of reviews.

Things You’ll Do Here:

Supervision

• Supervise a team of Utilization Review Nurses providing guidance and training as needed.
• Work with the leadership team to develop and implement UM policies, procedures, and guidelines that ensure appropriate utilization of healthcare services.
• Monitor and analyze utilization data to audit accuracy and timely work as well as identify trends and opportunities for improvement.
• Collaborate with healthcare providers and clients to promote effective and efficient utilization of healthcare services.
• Conduct clinical reviews and assessments to determine medical necessity and appropriateness of care for all UM clientele, referring into Case Management or other programs as applicable.
• Monitor established production goals for the team as well as personal goals.
• Ensure compliance with regulatory and accreditation standards such as Medicare, Medicaid, and URAC guidelines.
• Provide clear communication, education, and training to UM team members.
• Maintain accurate and complete records of utilization management activities to achieve desired business outcomes.
• Ensuring timely and accurate communication with healthcare providers and payers regarding utilization management decisions.
• Adheres to quality standards, confidentiality, and UM policies and procedures with the highest level of personal and professional integrity.

Utilization Management

• Conduct utilization review for members to ensure appropriateness, quality, and cost-effectiveness of care.
• Monitor member treatment plans and medical records to ensure compliance with established guidelines and standards.
• Evaluate medical necessity and the appropriateness of requested services, procedures, and treatments based on evidence-based criteria.
• Communicate with healthcare providers and insurance companies to ensure appropriate utilization of resources and services.
• Collaborate with the healthcare team to identify opportunities for cost containment and quality improvement.
• Provide education and counseling to members and their families regarding their medical needs and available resources.
• Utilize software systems to manage and document utilization review activities accurately.
• Maintain knowledge of regulations, accreditation standards, and industry best practices related to utilization management.

Reasonable accommodation may be made to enable individuals with disabilities to perform essential duties.

What You’ll Bring to the Team:

• 5+ years of experience UM/QI experience in a managed care environment
• 2+ years of experience in acute care clinical and/or surgical hospital environment
• Current RN or LPN in residing state.
• Working knowledge of industry coding and guidelines, ICD-10, CPT, HCPCS and Revenue codes, CMS and/or URAC guidelines, etc.
• Working knowledge of evidence-based criteria such as MCG and Health Plan Guidelines
• Strong aptitude for relationship building with a highly effective communication style.
• Ability to work in a fast-paced, detailed, deadline-driven environment.

A plus if you have:

• Health insurance experience
• Experience working with MCG criteria, MCG certification is a plus. Without, a MCG certification will be required within 6 months of hire.
• RN or LPN in compact states: Alabama, Arizona, Arkansas, Colorado, Delaware, Florida, Georgia, Guam

Where You’ll Work

This role is remote.

Why You Will Love Working Here

We offer employee perks that go beyond standard benefits and compensation packages – see below!

At Valenz, our team is committed to delivering on our promise to engage early and often for smarter, better, faster healthcare. We want everyone engaged within our ecosystem to be strong, vigorous, and healthy. You’ll find limitless growth opportunities as we grow together. If you're ready to utilize your skills and passion to make a significant impact in the healthcare self-funded space, Valenz might be the perfect place for you!

Perks and Benefits

• Generously subsidized company-sponsored medical, dental, and vision insurance
• Company-funded HRA
• 401K with company match and immediate vesting
• Flexible working environment
• Generous Paid Time Off
• Paid maternity and paternity leave
• Paid company holidays
• Community giveback opportunities, including paid time off for philanthropic endeavors

At Valenz, we celebrate, support, and thrive on inclusion, for the benefit of our associates, our partners, and our products. Valenz is committed to the principle of equal employment opportunity for all associates and to providing associates with a work environment free of discrimination and harassment. All employment decisions at Valenz are based on business needs, job requirements, and individual qualifications, without regard to race, color, religion or belief, national, social, or ethnic origin, sex (including pregnancy), age, physical, mental or sensory disability, HIV Status, sexual orientation, gender identity and/or expression, marital, civil union or domestic partnership status, past or present military service, family medical history or genetic information, family or parental status, or any other status protected by the laws or regulations in the locations where we operate. We will not tolerate discrimination or harassment based on any of these characteristics.