9 Aug 2017

Full-Time Utilization Review Nurse

Greenkey Resources LLC – Posted by rhodgesLos Angeles, California, United States


Job Description

Green Key Resources LLC has a prominent client that provides the kind of health insurance we would want for ourselves. This means that we get to be creative and to build an excellent health insurer from the ground up.

We’re looking for experienced clinicians to join the fast-growing Utilization Management team in our Los Angeles office. We’re working to bring a new level of service to utilization review and ensure Client’s members receive access to appropriate care in a timely, transparent way. As a Utilization Review Nurse, you will determine the medical appropriateness of inpatient and outpatient services by reviewing clinical information and applying evidence-based guidelines. You will also interact with providers, members, and internal service team to obtain necessary information and communicate approval determinations.

Your primary responsibility in this role will be to conduct initial assessments of medical necessity for inpatient and outpatient services. In order to do so, you will need to:

  • Collect relevant medical information (via telephone and fax) and apply the appropriate evidence-based guidelines and medical policy
  • Meet required decision-making timeframes, including promptly triggering escalation for cases requiring physician review
  • Clearly document all communication and decision-making within our utilization review tracking platform, ensuring a peer could easily reference and understand your decision
  • Demonstrate the highest level of professionalism, accountability, and service in your interactions with Client’s teammates, customer service, providers, and members
  • Learn and use Client’s tools and processes to perform and properly track all utilization reviews, as well to refer members for further care engagement when needed
  • Develop a working familiarity with applicable regulatory and accreditation requirements
  • Participate in quality improvement activities as requested
  • Provide feedback into improving Client’s overall operations and member/provider experience
  • Maintain continued professional growth and education to meet continuing education requirements and demonstrate knowledge & understanding of current nursing care practice

Required experience and qualifications include:


  • Active, unrestricted RN (BSN preferred) license in California
  • Willingness to obtain additional state licenses as needed for Oscar’s growth (with Oscar’s support)
  • Experience of at least:
  • Two years utilization review experience at a managed care plan or provider organization and
  • Five years healthcare experience (including at least 2 years clinical practice in an acute care setting, i.e., ER or hospital)
  • Able to multi-task and manage tasks to completion on a timely basis and in an organized fashion
  • Comfortable with technology; willing and able to learn new software tools
  • Clear written and spoken communication, including a poised phone presence
  • Flexible mindset: we are a fast-moving and evolving startup

Salary: $105,ooo-110,000 based on experience

Forward resume to Rachel Hodges, Senior RM at rhodges@greenkeyllc.com

Job Categories: Medical and Health. Job Types: Full-Time. Salary: 100,000 and above. Job expires in 78 days.

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