Utilization Review Nurse RN- Remote PST hours

About Lucent Health Lucent Health combines top-tier claims management with a compassionate, human-focused, data-driven care management solution. This approach helps self-insured employers provide care management that enables health plan participants to make smarter, cost-saving healthcare decisions. Continuous data analytics offer ongoing insights, ensuring participants receive the right care, at the right cost, at the right time. Join us as we build a company that aims to be a better health benefits partner for self-insured employers. Company Culture We believe that the success of Lucent Health relies on having employees who are honest, ethical and hardworking. These values are the foundation of Lucent Health. Honest

• Transparent Communication: be open and clear in all interactions without withholding crucial information
• Integrity: ensure accuracy in reporting, work outputs and any tasks assigned
• Truthfulness: provide honest feedback and report any issues or challenges as they arise
• Trustworthiness: build and maintain trust by consistently demonstrating reliable behavior

Ethical

• Fair Decision Making: ensure all actions and decisions respect company policies and values
• Accountability: own up to mistakes and take responsibility for rectifying them
• Respect: treat colleagues, clients and partners with fairness and dignity
• Confidentiality: safeguard sensitive information and avoid conflicts of interest

Hardworking

• Consistency: meet or exceed deadlines, maintaining high productivity levels
• Proactiveness: take initiative to tackle challenges without waiting to be asked
• Willingness: voluntarily offer to assist in additional projects or tasks when needed
• Adaptability: work efficiently under pressure or in changing environments

Summary: The Utilization Review RN shall work in a collaborative fashion to promote the provision of quality care and cost-effective outcomes that will enhance the physical, psychosocial, and vocational health of the plan participants in accordance with the policies and procedures of Lucent Health Care Management, LLC, URAC UM Standards, and the laws and established practices associated with medical management. Responsibilities: The Utilization Review RN shall be responsible for all aspects of the utilization review process as directed by the Supervisor of Utilization Review.

• Activities shall include, but not be limited to, inpatient and outpatient review, admission review, discharge planning, retrospective review, readmission review, large case management screening/identification, identification and communication of large claim potential, development, review, revision, and implementation of quality improvement programs and protocols (as directed by the Supervisor of Utilization Review), excellent coordination and communication of medical information with large case and disease management and payers (as appropriate), appropriate usage of physician advisors, adherence to URAC requirements and LHCM. documentation, quality, and productivity standards, completion of requests for attending physician statements, and customer service support.
• The Utilization Review RN is responsible, on a daily basis, for completing the "tickler", returning telephone and voice mail messages within established timeframes, accurately and adequately documenting all interactions, checking and responding to e-mail, faxes, and regular mail, interacting with all internal and external customers in a positive, proactive, and helpful manner, and providing any and all necessary support to the Supervisor of Utilization Review and the entire LHCM team.
• They shall complete the LHCM Orientation and Training Course that includes policies and procedures and URAC UM Standards, be familiar and supervise the activities of the non-clinical administrative staff relative to the UR function, utilize telephones, access the server, or other software that may be provided by LHCM to perform daily duties, and be familiar with the Clinical Review Guidelines.
• They shall be responsible for providing all aspects of excellent customer service and development, maintaining confidentiality, completing an orientation and participating in an ongoing training program which includes policies and procedures, URAC UM Standards, and clinical review guidelines.
• They only certifies care or services. If the care or service requested is not meeting initial clinical review criteria, then the case is referred to a peer clinical reviewer.

Qualifications:

• Registered Nurse with a minimum of 5 years of recent clinical nursing experience
• Bachelor's Degree and/or Certification in UR, Case Management, or a related field-preferred
• Excellent Written and Oral Communication
• Positive, proactive team-oriented approach/attitude
• Excellent Computer skills
• Holds an active, unrestricted RN license that allows him/her to practice in a state or territory of the United States.

Equal Employment Opportunity Policy Statement Lucent Health is an Equal Opportunity Employer that does not discriminate based on actual or perceived race, color, creed, religion, alienage or national origin, ancestry, citizenship status, age, sex or gender (including pregnancy, childbirth and related medical conditions), gender identity, gender expression, transgender status, sexual orientation, marital status, military service and veteran status. Apply To This Job