Utilization Management Nurse (LPN/RN)

U.S. healthcare is frustrating and deeply flawed. Cedar's mission is to drive better outcomes for everyone involved, including providers, insurance companies and the people they serve. At a time when consumer-friendly healthcare experiences are more critical than ever, our platform is uniquely equipped to solve problems that lead to billing issues and administrative waste. At Cedar, know that your work will have a meaningful impact on people's lives.
Role
This position is responsible for proactively handling inpatient and outpatient utilization to assure that medical care is appropriate, efficient, and medically vital. Supports planning efforts, coordination of transition of care and manage utilization through appropriate review of authorization requests. Analyzes and evaluates medical records and other health data to render medical necessity determinations using specific clinical criteria while adhering to regulatory turn-around times to provide review outcomes to members and providers in accordance with notification standards. Implements utilization management processes to coordinate medical services with other Cedar Partners, as well as local, state and federal programs.
Responsibilities

• Applies clinical nursing skills to support the coordination, documentation and communication of medical services and/or benefit administration determinations.
• Use clinical knowledge, interpersonal skills, and independent critical thinking skills towards interpreting criteria, policies, and procedures to provide the best and most appropriate treatment, care or services for members.
• Collaborate with providers, members, or other parties to facilitate the most efficient care and treatment plans.
• Maintain curiosity around new ways of doing business and new opportunities to further support our members and our business unit needs.
• The ideal candidate will be flexible as there are some occasions that may require additional hours worked on any given day, week, weekend, or holiday.
• Be solution oriented and promote top quality work while improving processes to promote simplicity.

Requirements:

• We are looking for a Licensed Practical Nurse or Registered Nurse (LPN/RN) in the (appropriate state) with no current or prior disciplinary action on license.
• Proficiency using MS Office programs and Google suite.
• Ability to work independently and autonomously under general instructions while collaborating with other team members as needed.
• Capability to efficiently use multiple systems on multiple screens simultaneously.
• Ability to demonstrate successful team leadership, relationship building, critical analysis, and written and verbal communication skills.
• Proven knowledge of payers, payer systems, cost effective utilization management and InterQual or other similar systems.
• Ability to take direction and critique as a valuable tool to improve and learn.

Nice to haves:

• One year Utilization Review or Case Management experience.

Please note that satellite and wireless internet service (wi-fi) is NOT allowed for this role and you may not be the direct caregiver of any family member during working hours. A quiet private work space with a locked door is required.
#LI-Remote
What do we offer to the ideal candidate?

• A chance to improve the U.S. healthcare system at a high-growth company! Our leading healthcare financial platform is scaling rapidly, helping millions of patients per year
• Unless stated otherwise, most roles have flexibility to work from home or in the office, depending on what works best for you
• Unlimited PTO for vacation, sick and mental health days-we encourage everyone to take at least 20 days of vacation per year to ensure dedicated time to spend with loved ones, explore, rest and recharge
• 16 weeks paid parental leave with health benefits for all parents, plus flexible re-entry schedules for returning to work
• Diversity initiatives that encourage Cedarians to bring their whole selves to work, including three employee resource groups: be@cedar (for BIPOC-identifying Cedarians and their allies), Pridecones (for LGBTQIA+ Cedarians and their allies) and Cedar Women+ (for female-identifying Cedarians)
• Competitive pay, equity (for qualifying roles) and health benefits that start on the first of the month following your start date (or on your start date if your start date coincides with the first of the month)
• 401k plan with 3% employer non-election contribution
• Access to hands-on mentorship, employee and management coaching, and a stipend for learning and development resources to help you grow both professionally and personally

About us
Cedar was co-founded by Florian Otto and Arel Lidow in 2016 after a negative medical billing experience inspired them to help improve our healthcare system. With a commitment to solving billing and patient experience issues, Cedar has become a leading healthcare technology company fueled by remarkable growth. Over the past several years, we've raised more than $350 million in funding from investors such as Andreessen Horowitz and Tiger Global, bringing Cedar's valuation to $3.2 billion.
Today, Cedar helps over 15 million patients annually-and partners with more than 50 leading healthcare providers, including Yale New Haven Health, Summit Health, Novant Health, Allina Health, Providence, ChristianaCare, Blue Cross Blue Shield of Arizona, CommonSpirit Health and Blue Cross Blue Shield of Massachusetts.