UM QA Utilization Management

Utilization Management QA RN – Lead II – BPM

UST Health Proof 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 4,000 people spread across the world. Our brand is built on the strong foundation of simplicity, integrity, people‑centricity, and leadership. We stay inspired in our goal to unburden healthcare and ensure it reaches all, equitably and effectively.

The Utilization 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.

• 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.

• Nursing 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 US 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 (Share Point, Care Advance, NASCO, 3270, MCMS/AMP, CCDB, IKA and Portico system).
• Basic knowledge of ICD9/ICD 10 and CPT Codes.
• MEDCO, Member Health Record, VDA (Virtual Desk Top), Care Advance.
• Knowledge of local, state and federal regulations (PA250, PA350, DOL, ERISA, HIPAA).
• Leadership experience.
• Ability to use clinical assessments and interventions.
• Knowledge of effective communication techniques and theories.

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

Compensation can differ depending on factors including but not limited to the specific office location, role, skill set, education, and level of experience. UST Health Proof 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: $65,000-$85,000

Full‑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 throughout the year), 10 paid holidays, and are eligible for paid bereavement leave. They are eligible to participate in the Company’s 401(k) Retirement Plan with employer matching. They and their dependents residing in the US are eligible for medical, dental, and vision insurance, as well as the following Company‑paid benefits: basic life insurance, accidental death and disability insurance, and short‑ and long‑term disability benefits.

Regular employees may purchase additional voluntary short‑term disability benefits, and participate in a Health Savings Account (HSA) as well as a Flexible Spending Account (FSA) for healthcare, dependent child care, and/or commuting expenses. Certain regular employees may have the potential for quarterly incentive‑based bonuses and or commissions depending on role. Benefits offerings vary in Puerto Rico.

Part‑time employees receive 6 days of paid sick leave each year (pro‑rated for new hires…