Utilization Review Nurse

About the position Sidecar Health is redefining health insurance with a mission to make excellent healthcare affordable and attainable for everyone. As a Utilization Review Nurse, you will play a crucial role in evaluating the medical necessity and quality of healthcare services for our members, ensuring adherence to established guidelines. This position requires a proactive approach to reviewing upcoming services and good faith estimates, as well as drafting letters based on Sidecar Health policies. You will be at the forefront of transforming healthcare in the United States, working alongside a passionate team dedicated to fixing a broken system and making it more personalized, affordable, and transparent. In this role, you will review and analyze medical records to assess the appropriateness and necessity of healthcare services. You will ensure compliance with established clinical guidelines, policies, and regulatory requirements while collaborating with healthcare providers to gather additional information when needed. Utilizing Milliman Care Guidelines (MCG), you will evaluate the medical necessity and appropriateness of proposed and ongoing treatments. Additionally, you will evaluate good faith estimates and "prebills" to determine scheduled care, highlighting any care that may not be included in the estimate, such as labs, radiology, and pre-op visits. Your responsibilities will also include drafting letters to send to members outlining benefits and other considerations, collaborating with the provider team and Member care team to evaluate care shopping options, and participating in quality improvement initiatives to enhance the efficiency and effectiveness of the clinical review process. You will review claims reconsiderations and appeals, providing expert guidance to ensure accurate processing and resolution of issues related to coverage determination, and assess claims for balance billing protections to ensure compliance with applicable regulations and internal policies. Responsibilities • Review and analyze medical records to assess the appropriateness and necessity of healthcare services , • Ensure compliance with established clinical guidelines, policies, and regulatory requirements , • Collaborate with healthcare providers to gather additional information when needed , • Utilize Milliman Care Guidelines (MCG) to evaluate the medical necessity and appropriateness of proposed and ongoing treatments , • Evaluate good faith estimates and 'prebills' to determine scheduled care, including highlighting care that may not be included in the estimate , • Draft letters to send to members outlining benefits and other considerations , • Collaborate with provider team and Member care team to evaluate care shopping options , • Participate in quality improvement initiatives to enhance the efficiency and effectiveness of the clinical review process , • Review claims reconsiderations and appeals, providing expert guidance to ensure accurate processing and resolution of issues coverage determination , • Assess claims for balance billing protections to ensure compliance with applicable regulations and internal policies Requirements • Clinical credentials (RN) , • 5+ years of experience as a nurse providing care to patients, preferably in a hospital setting , • Medical billing and/or coding experience in a provider or payor setting , • Excellent written communication skills with experience drafting member, patient, and provider-facing letters , • Ability to think critically and make decisions with limited information , • Exceptional cross-functional collaboration skills with the ability to make recommendations to leadership , • Ability to problem solve and handle escalated cases , • Experience with Microsoft Suite , • Prior authorization experience (preferred) , • Bachelor's degree Nice-to-haves Benefits • Competitive salary , • Bonus opportunity , • Equity package , • Comprehensive Medical, Dental, and Vision benefits , • 401k retirement plan , • Paid vacation and company holidays , • Opportunity to make an impact at a rapidly growing mission-driven company transforming healthcare in the U.S Apply Job!