Utilization Management Nurse Analyst (Remote)

Availity delivers revenue cycle and related business solutions for health care professionals who want to build healthy, thriving organizations. Availity has the powerful tools, actionable insights and expansive network reach that medical businesses need to get an edge in an industry constantly redefined by change.

The position of UM Nurse Analyst will report to the Medical Director of Availity's Auth AI solution. The UM Nursing Analyst is responsible for the interpretation of payer medical policy guidelines and the construction of NLP/AI-enabled decision trees that accurately reflect medical necessity criteria.

The role requires in-depth knowledge of utilization management principles, the role and purpose of medical necessity guidelines and prior authorization adjudication practices. This individual will work in a team environment and will be expected to perform highly complex tasks while collaborating with team members with both clinical and engineering/programming backgrounds. The successful candidate will be detail oriented with strong analytic reasoning skills, demonstrate strong communication and organizational skills while remaining open-minded, embracing change and the spirit of innovation.

Sponsorship, in any form, is not available for this position.

Location: Remote, US

Why you want to work on this team:

• Dynamic, collaborative group working on innovative technologies to disrupt the status quo and solve the problem of prior authorization in healthcare.
• Opportunity to work directly on cutting edge AI technology and its application to the healthcare industry.

Role qualifications:

• Bachelor's degree in nursing.
• At least 3+ years of experience in an outpatient Utilization Management program, either with an insurer or with a healthcare provider OR equivalent clinical experience with familiarity with prior authorization submission practices.
• Additional experience in fields of billing / coding, claims review or inpatient utilization management, while not necessary, would enhance the application.
• "Computer smart" - General power user of technology and confident with navigating new technologies and applications.
• Familiarity and understanding of interpreting medical records to be able to identify how physicians may document conditions and findings.
  

You will set yourself apart:

• If you have exceptional critical thinking and reasoning skills.
• If you can synthesize complex, abstract problems, and collaborate effectively with team members with diverse skillsets to create solutions.
• If you are self-motivated and a quick learner with an ability to multi-task.

What you will be doing:

• Reviewing payer Medical Policy Guidelines to identify pertinent medical necessity criteria related to specific Procedural codes or CPT codes.
• Use programming language to construct attestation questions that reflect medical necessity criteria.
• Assign coded medical constructs to attestation trees based on clinical relevance to facilitate automation of responses to the questions.
• Identify medical terms that should be added to the existing vocabulary of coded medical concepts.
• Serve as Subject Matter Expert and general medical resource to engineering teams and developers

Availity culture and benefits:

• Availity is a certified "Great Place to Work", a "Best Workplaces for Technology Companies", a "Best Workplaces for Women" and a "Best Workplaces for Millennials"!
• Culture is important to us and there are many ways for you to make your mark here!
• We have several Diversity & Inclusion teams and various ways to engage with fellow Availity associates. "AvaiLadies", "Beyond Black", "HOLA", "Availity Pride", "VetAvaility" a Young Professionals Group and "She Can Code IT" a group for women in tech are some of the groups you can get involved in.
• Availity is a culture of continuous learning. We have many resources and experts in our tech stack and in our industry that can help get you there too!
• We offer a competitive salary, bonus structure, generous HSA company contribution, healthcare, vision, dental benefits and a 401k match program that you can take advantage of on day one!
• We offer unlimited PTO for salaried associates + 9 paid holidays. Hourly associates start at 19 days of PTO and go up from there with all the same holiday benefits.
• Interested in wellness? We allow our associates to reimburse up to $250/year for gym memberships, participation in racing events, weight management programs, etc.
• Interested in furthering your education? We offer education reimbursement!
• Availity offers Paid Parental Leave for both moms and dads, both birth parents and adoptive parents.
• Want to work for an organization that gives back to the community? You're at the right place! Availity partners with various organizations, both locally and nationally, to raise awareness, funds and morale as our staff members volunteer their time and funds to engage the organizations campaign.

Next steps:

After you apply, you will receive text/email messages thanking you for applying and then you will continue to receive more text/email messages alerting you as to where you are in the recruitment process.

Interview process:

• Recruiter resume review
• Manager resume review
• Recruiter video interview
• Manager video interview
• Panel video interview

Availity is an equal opportunity employer and makes decisions in employment matters without regard to race, religious creed, color, age, sex, sexual orientation, gender identity, gender expression, genetic information, national origin, religion, marital status, medical condition, disability, military service, pregnancy, childbirth and related medical conditions, or any other classification protected by federal, state, and local laws and ordinances.

Availity is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.

NOTICE: Federal law requires all employers to verify the identity and employment eligibility of all persons hired to work in the United States. When required by state law or federal regulation, Availity uses I-9, Employment Eligibility Verification in conjunction with E-Verify to determine employment eligibility. Learn more about E-Verify at http://www.dhs.gov/e-verify.

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