Utilization Management Nurse II

HMA is the premier third-party health plan administrator across the PNW and beyond. We relentlessly deliver on our promise to provide medium to large-size employers with customized health plans. We offer various high-quality, affordable healthcare plan options supported with best-in-class customer service.
We are proud to say that for three years, HMA has been chosen as a 'Washington's Best Workplaces' by our Staff and PSBJ™. Our vision, 'Proving What's Possible in Healthcare™,' and our values, People First!, Be Extraordinary, Work Courageously, Own It, and Win Together, shape our culture, influence our decisions, and drive our results.
What we are looking for: We are always searching for unique people to add to our team. We only hire people that care deeply about others, thrive in evolving environments, gain satisfaction from being part of a team, are motivated by tackling complex challenges, are courageous enough to share ideas, action-oriented, resilient, and results-driven.
What you can expect: You can expect an inclusive, flexible, and fun culture, comprehensive salary, pay transparency, benefits, and time off package with plenty of personal development and growth opportunities. If you are looking for meaningful work, a clear purpose, high standards, work/life balance, and the ability to contribute to something important, find out more about us at: https://www.accesshma.com/
How YOU will make a Difference:
The Utilization Management Nurse collaborates with external entities such as Brokers, Group Contacts, and Stop Loss supports to provide updated information on case specifics within HIPAA regulations. The Utilization Management Nurse is responsible for efficient utilization of health services by providing monitoring of member utilization and claim patterns; and makes referrals to Case Manager nurses for ongoing case management for complex care.
What YOU will do:

• Performs Utilization Management and applies first the terms of the SPD (Summary Plan Description), considering any benefit limitations/exclusions and PPO status of requesting provider/facility.
• Reviews are conducted using approved criteria for appropriateness of services, setting/level of care and length of stay.
• Provides ongoing review management of treatment progress as needed to provide personalized support and care coordination for complex, catastrophic or ongoing chronic medical conditions.
• Evaluates services requested to meet an individual's health care needs, with the goal to provide personalized management to promote and ensure continuity of care coordination.
• Other duties as assigned

Knowledge, Experience, and Key Attributes needed for Success:

• An Associate's degree or equivalent professional experience required
• Active LPN/RN clinical license required
• 3-5+ years of clinical nursing experience
• Knowledge of Utilization Review processes (Preferred)
• Strong experience in clinical practice with diverse diagnoses
• Strong problem solving and critical thinking skills
• Excellent, client-facing verbal and written communication skills
• Behavioral health experience (Preferred)
• Ability to be self-motivated and self-directed
• Enjoys the pace and rhythm of a deadline-oriented environment with strong prioritization skills
• Proficiency with Electronic Health Records, Microsoft Office applications (Outlook, Word, DOSS)

Compensation:
The base salary range for this position in the greater Seattle area is $85,000 - $105,000 and varies dependent on geography, skills, experience, education, and other job or market-related factors. Performance-based incentive bonus(es) is available. In addition, HMA provides a generous total rewards package for full-time employees that includes: seventeen (IC) days paid time off; eleven paid holidays, one paid personal and one paid volunteer day; company-subsidized medical, dental, vision, and prescription insurance; company-paid disability, life, and AD&D insurances; voluntary life insurances; HSA and FSA pre-tax programs; 401(k)-retirement plan with company match; wellness incentive and reimbursement; remote work and continuing education reimbursements; discount program; parental leave; and a charitable giving match. For more information about HMA, visit www.accesshma.com .
Disclaimer: The salary, other compensation, and benefits information are accurate as of this posting date. HMA reserves the right to modify this information at any time, subject to applicable law.
How we Support your Work, Life, and Wellness Goals
We offer a comprehensive total rewards package including: competitive pay; annual incentive; wellness programs; medical, dental, and vision insurance; 401K retirement plan with match; generous PTO and holidays; an onsite gym; life, AD&D, short and long-term disability insurances; an Employee Assistance Plan with additional mental health support; free parking and easy freeway access to I-405 and I-520; a stocked kitchen on-site with subsidized snacks and refreshments; year-round wellness activities; monthly events; paid volunteer hours and more!
HMA is primarily a remote workforce, requires a reliable internet connection, and provides all hardware. Some roles are required onsite 1-3 days per week/month while other roles are 100% remote.
A background screen prior to employment is required.
Protected Health Information (PHI) Access Healthcare Management Administrators (HMA) employees may encounter protected health information (PHI) in the regular course of their work. All PHI shall be used and disclosed on a need-to-know-basis and according to HMA's standard policies and procedures.
HMA is an Equal Opportunity Employer