What You'll be doing

• Performs utilization review services in compliance with federal and state regulations, and the URAC standards for client members seeking healthcare treatment and services.
• Obtain, analyze and document all supporting clinical within the documentation record.
• Complete a timely review of health care services utilizing and documenting the appropriate medical criteria used to make a clinical determination.
• Complete timely written and / or verbal communication of pre-certifications and concurrent review determinations for healthcare services to all parties required by regulations, URAC standards and Arcadia policies.
• Communicate with the Medical Director and Peer Reviewer(s) for cases requiring review of medical necessity, appropriate treatment, intensity/ number of inpatient and outpatient treatment or quality of care issues.
• Interface with ordering providers and provider organizations on a routine basis. In some instances, communication with members or their representatives may be appropriate.
• Initiate the referral of targeted patients into organized disease management programs to assist with continuity and quality of care.
• Manage and document after-hours phone calls from members and providers on a rotational basis
• Maintain confidentiality of member information, case records and file entries
• Participate in quality management activities
• Responsible for sending client specific benefit exhaustion letters upon request.
• Assists with coordination and the design and development of clinical and client specific reports.
• May assist in the development of materials and packets for the QM/ UM Committee meetings, the documentation of minutes, preparation of spreadsheets, data collection and analysis, and follow-up tasks.
• Maintain current knowledge and comply with regulatory requirements for multiple jurisdictions and medical groups
• Integrate ongoing, accurate knowledge of medical group guidelines and URAC standards into daily duties
• Responsible for continued professional growth and education that reflects knowledge and understanding of current nursing care practice as outlined in the Illinois Nurse Practice Act.
• Interacts with the IT Department for technical support related to computer systems, upgrades and other data
• Other responsibilities as assigned

What You'll Bring

• Registered Nurse with an active and unrestricted Illinois state License.
• Five years of experience in a variety of health care settings.
• Knowledge of utilization review, managed care and community health.
• State of Illinois requires Nursing Professional Staff to complete 20 hours of CE per 2-year license renewal cycle
• Computer skills including MS Word, Excel, MS Access, etc.
• Strong organizational, writing and speaking skills necessary.
• Ability to prioritize and react based on rapidly changing business needs.
• Excellent clinical judgment, compassion and a positive attitude

Would Love for You to Have

• An advanced degree or certification in Case Management, Utilization Review and/or Quality
• Interest in Informatics
• Knowledge in Population Health and Disparities
• Previous Health insurance experience

What You'll Get

• Flexible hours, Working remote, Collaborating with a great team!
• Be a part of a mission driven company that is transforming the healthcare industry by changing the way patients receive care
• A flexible, remote friendly company with personality and heart
• Employee driven programs and initiatives for personal and professional development
• Be a member of the Arcadian and Barkadian Community

About Arcadia
Arcadia.io helps innovative healthcare systems and health plans around the country transform healthcare to reduce cost while improving patient health. We do this by aggregating massive amounts of clinical and claims data, applying algorithms to identify opportunities to provide better patient care, and making those opportunities actionable by physicians at the point of care in near-real time. We are passionate about helping our customers drive meaningful outcomes. We are growing fast and have emerged as the market leader in the highly competitive population health management software and value-based care services markets, and we have been recognized by industry analysts KLAS, IDC, Forrester and Chilmark for our leadership. For a better sense of our brand and products, please explore our website , our online resources , and our interactive Data Gallery .
This position is responsible for following all Security policies and procedures in order to protect all PHI under Arcadia's custodianship as well as Arcadia Intellectual Properties. For any security-specific roles, the responsibilities would be further defined by the hiring manager.