Lead I - Bpm

Who we are:

UST HealthProof is a dynamic company with a mission to lower the cost of care and deliver the future of healthcare. Our consumer-centric approach gives our health plan customers a modern infrastructure and reduced administrative costs, helping to drive better business results for our customers — and better outcomes for our communities.

We achieve this mission together through teamwork, communication, collaboration, and focus. Our employees are our greatest assets, and we invite you to apply to be a part of our journey toward making a difference in healthcare in the United States.

You Are

Perform prospective, concurrent and retrospective review of inpatient, outpatient, ambulatory and ancillary services to ensure medical necessity, appropriate length of stay, intensity of service and level of care, including appeal requests initiated by providers, facilities and members. May establish care plans and coordinate care through the health care continuum including member outreach assessments.

The Opportunity

• Analyze, research, respond to and prepare documentation related to retrospective review requests and appeals in accordance with local, state and federal regulatory and designated accreditation (e.g. NCQA) standards.
• Research and resolve issues related to benefits, member eligibility, non-elective and non-authorized services, coordination of benefits, care coordination, etc.
• Establish, coordinate and communicate discharge planning needs with appropriate internal and external entities.
• Follow out-of-area/out-of-network services and make recommendations on patient transfer to in-network services and/or alternative plans of care.
• Develop and deliver targeted education for provider community related to policies, procedures, benefits, etc.
• Other duties may be assigned based on designated department assignment. This position description identifies the responsibilities and tasks typically associated with the performance of the position. Other relevant essential functions may be required.
• Identify and document quality of care issues; resolve or route to appropriate area for resolution.
• As needed and in conjunction with Provider Services, may identify and negotiate reimbursement rates for non-contracted providers for services.
• Review, research and authorize requests for authorization of elective, direct, ancillary, urgent, emergency, etc. services. Contact appropriate medical and support personnel to identify and recommend alternative treatment, service levels, length of stays, etc. using approved clinical protocols.
• Analyze patterns of care associated with disease progression; identify contractual services and organize delivery through appropriate channels.

Education

What you need:

• Continuous learning, as defined by the Company’s learning philosophy, is required.
• Certification or progress toward certification is highly preferred and encouraged.
• Certification in Case Management may be preferred based upon designated department assignment.
• Registered Nurse with current unrestricted Registered Nurse license required.

Experience

• One (1) year health insurance plan experience or managed care environment preferred.
• Demonstrated clinical knowledge and experience relative to patient care and health care delivery processes.
• Four (4) to Six (6) years of clinical experience which may include acute patient care, discharge planning, case management, and utilization review, etc.

Skills/Knowledge/Abilities (ska) Required

• Knowledge of policies and procedures, member benefits and community resources.
• Other related skills and/or abilities may be required to perform this job based upon designated department assignment.
• Excellent written and verbal communication skills. Excellent customer service and interpersonal skills.
• Knowledge of current standard medical procedures/practices and their application as well as current trends and developments in medicine and nursing, alternative care settings and levels of service.
• Working knowledge of current industry Microsoft Office Suite PC applications.
• Ability to apply clinical criteria/guidelines for medical necessity, setting/level of care and concurrent patient management.
• Knowledge of applicable accreditation standards, local, state and federal regulations.

Compensation can differ depending on factors including but not limited to the specific office location, role, skill set, education, and level of experience.  As required by local law, UST HealthProof provides a reasonable range of compensation for roles that may be hired in California, Colorado, New York City or Washington as set forth below.  

Role Location: Range of Starting Pay for Role

Remote: $55,000-$85,000

Our associates are eligible for employee stock options, 401K matching, and covered from day 1 for paid vacation and sick time, and healthcare, dental, vision, life and disability insurance benefits.

What We Believe

We’re proud to embrace the same values that have shaped UST HealthProof since the beginning. Since day one, we’ve been building enduring relationships and a culture of integrity. And today, it's those same values that are inspiring us to encourage innovation from everyone, to champion diversity and inclusion, and to place people at the center of everything we do.

Humility

We will listen, learn, be empathetic and help selflessly in our interactions with everyone.

Humanity

Through business, we will better the lives of those less fortunate than ourselves.

Integrity

We honor our commitments and act with responsibility in all our relationships.

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, or status as a protected veteran.

UST HealthProof reserves the right to periodically redefine your roles and responsibilities based on the requirements of the organization and/or your performance.