UST HealthProof is a trusted partner for health plans, delivering an integrated ecosystem designed to optimize health plan operations. Through our Business Process as a Service (BPaaS) solutions, we expertly manage complex administrative tasks, enabling our customers to focus on prioritizing the well-being of their members. Guided by our commitment to simplicity, honesty, and leadership, we collaborate with our customers to overcome challenges and work toward making affordable health care accessible to everyone.

Our organization boasts a strong global presence, supported by a dedicated workforce of over 4,000 professionals distributed worldwide.

Our brand stands firmly on the principles of simplicity, integrity, people-centricity, and leadership. We remain inspired by our mission to unburden healthcare and ensure it is delivered equitably and effectively to all.

In this role, the Utilization Review RN is responsible for performing prospective, concurrent, and retrospective reviews of inpatient, outpatient, ambulatory, and ancillary services. These reviews ensure medical necessity, appropriate length of stay, intensity of service, and level of care, including handling appeal requests initiated by providers, facilities, and members. The RN may also establish care plans and coordinate care throughout the healthcare continuum, which could include conducting member outreach assessments.

Key Responsibilities

Review, research, and authorize requests for elective, direct, ancillary, urgent, and emergency services Contact appropriate medical and support personnel to identify and recommend alternative treatments, service levels, and length of stays using approved clinical protocols Analyze, research, respond to, and prepare documentation related to retrospective review requests and appeals in accordance with local, state, and federal regulatory requirements and accreditation standards (such as NCQA) Establish, coordinate, and communicate discharge planning needs with internal and external entities Analyze patterns of care associated with disease progression, identify contractual services, and organize delivery through appropriate channels Research and resolve issues related to benefits, member eligibility, non-elective and non-authorized services, coordination of benefits, and care coordination Identify and document quality of care issues, resolving them or routing them to the appropriate area for resolution Manage out-of-area and out-of-network services, making recommendations on patient transfer to in-network services and/or alternative plans of care Develop and deliver targeted education to the provider community regarding policies, procedures, and benefits When needed, and in collaboration with Provider Services, identify and negotiate reimbursement rates for non-contracted providers for services Perform other duties as assigned based on departmental needs

Qualifications

US Registered Nurse with a current, unrestricted RN license Certification in Case Management may be preferred depending on department assignment. Certification or progress toward certification is highly preferred and encouraged Minimum of two years of clinical experience, which may include acute patient care, discharge planning, case management, and utilization review Demonstrated clinical knowledge and experience related to patient care and healthcare delivery processes At least one year of experience in a health insurance plan or managed care environment is preferred

Skills & Competencies

Excellent written and verbal communication skills, as well as strong customer service and interpersonal abilities Proficiency in Microsoft Office Suite and related PC applications Ability to apply clinical criteria and guidelines for medical necessity, setting or level of care, and concurrent patient management Knowledge of standard medical procedures and practices, including current trends and developments in medicine and nursing, as well as alternative care settings and levels of service Familiarity with policies and procedures, member benefits, and community resources Understanding of applicable accreditation standards, and local, state, and federal regulations Other related skills and abilities may be required to perform the job, depending on departmental assignment