Utilization Management QA RN

Utilization Management QA RN – Lead II – BPMUtilization Management QA 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.Who We Are:UST HealthProof is a trusted partner for health plans, offering an integrated ecosystem for health plan operations. Our BPaaS solutions manage complex admin tasks, allowing our customers to prioritize members' well-being. With our commitment to simplicity, honesty, and leadership, we navigate challenges with our customers to achieve affordable health care for all. We have a strong global presence and a dedicated workforce of over 4000 people spread across the world. Our brand is built on the strong foundation of simplicity, integrity, people‐centricity, and leadership.The OpportunityResponsible for training UM clinical staff on processes, policies, and systems.Participate & lead in development, implementation, and updating of training manuals.Oversee and mentor new employees during the initial training program.Work closely with the leadership team, QA, and subject matter experts 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.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 NeedNursing Diploma or Associates Degree in Nursing required.Bachelors in nursing (BSN) or related fields preferred.Registered Nurse with current unrestricted Registered Nurse license in any of the 50 U.S. states required.MCG certification preferred.5 years' experience in health related fields required.3 years' experience with UM, Appeals & Grievances, Claims, QA, CMS & MCG guidelines.Proficient in relevant PC applications (SharePoint, Care Advance, NASCO, 3270, MCMS/AMP, CCDB, IKA and Portico system).Basic knowledge of ICD-9/ICD-10 and CPT Codes.Knowledge of local, state and federal regulations (PA250, PA350, DOL, ERISA, HIPPA).Leadership experience.Ability to use clinical assessments and interventions.Knowledge of effective communication techniques and theories.CompensationRole Location: Remote. Compensation Range: $65,000–$85,000.BenefitsFull‐time, regular employees accrue up to 16 days of paid vacation per year, receive 6 days of paid sick leave each year (pro‐rated for new hires), 10 paid holidays, and are eligible for paid bereavement leave. Eligible for 401(k) retirement plan with employer matching. Medical, dental, and vision insurance for employees and dependents. Company‐paid benefits: basic life insurance, accidental death and disability insurance, short‐ and long‐term disability benefits. Optional voluntary short‐term disability, HSA, and FSA. Potential quarterly incentive‐based bonuses for certain employees. Benefits may vary in Puerto Rico.Part‐time employees receive 6 days of paid sick leave annually (pro‐rated for new hires) and may participate in the 401(k) plan with employer matching.Full‐time temporary employees receive 6 days of paid sick leave annually (pro‐rated for new hires) and eligibility to the 401(k) program with employer matching. Medical, dental, and vision insurance for employees and dependents.Part‐time temporary employees receive 6 days of paid sick leave annually.All U.S. employees who work in a state or locality with more generous paid sick leave benefits than specified here will receive the benefit of those sick leave laws.Equal Employment Opportunity StatementUST 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, status as a protected veteran, or any other applicable characteristics protected by law. We will consider qualified applicants with arrest or conviction records in accordance with state and local laws and "fair chance" ordinances.UST HealthProof reserves the right to periodically redefine your roles and responsibilities based on the organization's requirements and/or performance.What We BelieveAt UST HealthProof, we envision a bold future for American healthcare. Our values and guiding principles shape our operations.Guiding PrinciplesSimplicity – Simplifying complexity underlies everything we do.Integrity – Integrity is our currency to build relationships.People‐centricity – Everything we do reflects deep bonds with peers and customers.Leadership – Taking ownership, initiative, responsibility.MissionA future possible only when health plans are free from administrative burdens so they can truly focus on what matters more – the well‐being of their members.#J-18808-Ljbffr