Utilization Management Trainer and Quality RN

Role Description

Utilization Management Trainer and Quality RN

Lead II – BPM

Who We Are

Founded in 2016, we’ve become a trusted and valued partner for health plans and providers. We offer a modern integrated ecosystem of healthcare operations, processes, and products, with inherent scalability, efficiency, and predictable outcomes. Our BPaaS delivery solutions work behind the scenes to manage our customers’ complex admin operations, giving them elbow room to focus on their members’ needs and well-being.

Bending cost curves, guaranteeing outcomes, finding paths through roadblocks – that’s our way of life. Our customers count on us to safely navigate them through deadlocks. We have a strong global presence and a dedicated workforce of 4000+ people spread across the world.

Our brand is built on strong foundations of simplicity, honesty, and leadership, and we stay inspired in our goal to unburden healthcare and ensure it reaches all, equitably and effectively.

You Are

The Utilization Management Trainer and Quality RN is responsible for providing clinical and educational support assessments, analysis and coordination of the quality management program and assisting in the divisional accreditation process.

The Opportunity

• Responsible for training UM clinical staff on processes, policies, and systems.
• Participate & lead in the development, implementation, and updating of training manuals to reflect new approaches to training, departmental and/or system process changes and MCG criteria updates as needed.
• Oversee and mentor new employees during the initial training program.
• Work closely with the leadership team, QA, and subject matter experts external and internal to assess the learning environment and determine relevant resources for training.
• Educate staff in the clinical policies criteria and procedures of MCG as well as an overview of the department, general functions, responsibilities and department relationships with other departments.
• Develop and maintain all training materials and develop training packages with related materials assigned by leadership.
• Participate in development, testing and implementation of new programs and systems as assigned.
• Share performance information with operations and training management in an effort to determine next steps.
• Coordinate administrative activities with the leadership team, including class evaluations, updating files, class registration, scheduling classes, new hire system/software access, personnel information, and attendance management.
• Act as a “change agent” on behalf of Health Management and positively support the inception of new programs, systems, processes, software, and tools
• Implement ongoing training for experienced nurses.
• Document outcomes of educational processes and share with leadership.
  
  

This position description identifies the responsibilities and tasks typically associated with the performance of the position. Other relevant essential functions may be required.

What You Need

• 5 years’ experience clinical nursing experience in a hospital or skilled nursing facility
• 3 years’ experience with utilization management, QA, CMS & MCG guidelines.
• Nursing Diploma or Associates Degree in Nursing required; Bachelor’s in nursing (BSN) or related fields preferred.
• Continuous learning, as defined by the Company’s learning philosophy, is required.
• Certification or progress toward certification is highly preferred and encouraged.
• Registered Nurse with current unrestricted Registered Nurse license in any of the 50 US states required.
• Proficiency with clinical assessments and interventions
• Effectively communicate with internal and external leadership
• Effective project management skills to create and execute work plans.
• Ability to work independently and in a team environment.
• Proficient in MS software – Excel, Outlook, Teams and SharePoint
• Guiding Care experience preferred
• Tableau or PowerBI experience preferred.
• Proficiency in Care Advance, NASCO, 3270, MCMS/AMP, CCDB, IKA, Portico system, MEDCO, Member Health Record and VDA (Virtual Desktop)
• Intermediate knowledge of ICD9/ICD 10 and CPT Codes
• Intermediate knowledge of local, state and federal regulations (PA250, PA350, DOL, ERISA, HIPPA)
  
  

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 applicable law, UST provides a reasonable range of compensation for roles that may be hired in various U.S. markets as set forth below.

Role Location: Remote

Compensation Range: $70,000-$85,000

Our full-time, regular associates are eligible for 401K matching, and vacation accrual and are covered from day 1 for paid sick time, healthcare, dental, vision, life, and disability insurance benefits.

What We Believe

At UST HealthProof, we envision a bold future for American healthcare. Our values are the bedrock beliefs our organization holds dear. They not only define what our brand stands for but also serves as a compass guiding every action and decision.

Guiding Principles

These principles illuminate the path of ‘how’ we operate. They detail actions and behaviors we much embody to honor our values and achieve our goals.

Integrity

Integrity is our currency to build relationships. We believe in being open and honest. It is only natural when we have nothing to hide. It demonstrates that we are here to do the right thing, no matter who is watching.

People-Centricity

Everything that we do reflects our deep bonds with peers and customers. These aren't mere transactions, but transformational ties. They shape our culture and decisions, affirming that our true value lies in the lives we touch and impact.

Simplicity

Simplifying complexity underlines everything we do - this approach is what makes us unique. We come with an open mind and straightforward approach, cutting our way to the core with measurable and actionable insights.

Leadership

Taking ownership is about taking initiative, being in-charge and driving things to completion. It’s a brave choice to ‘own’ all aspects of our work, ensuring we take full responsibility for everything we handle.

Mission

A future possible only when health plans are free from administrative burdens so they can truly focus on what matters more – their members’ well-being.

#Healthproof

#CB

Skills

Healthcare,Trainers,Medical Management