Utilization Review Nurse

Sidecar Health is redefining health insurance. Our mission is to make excellent healthcare affordable and attainable for everyone. We know that to accomplish this lofty mission, we need driven people who will make things happen.

The passionate people who make up Sidecar Health’s team come from all over, with backgrounds as tech leaders, policy makers, healthcare professionals, and beyond. And they all have one thing in common—the desire to fix a broken system and make it more personalized, affordable, and transparent.

If you want to use your talents to transform healthcare in the United States, come join us!

*Must reside in Florida, Georgia, Kentucky, or Ohio for consideration*

About the Role

As a Utilization Review Nurse, you'll be at the forefront of evaluating the medical necessity and quality of healthcare services for our members, guaranteeing adherence to established guidelines. You will also be responsible for reviewing upcoming services and good faith estimates for our members and writing letters based on the Sidecar Health policy.

What You'll Do

• Utilize Milliman Care Guidelines (MCG) to evaluate the medical necessity and appropriateness of proposed and ongoing treatments for our members
• Participate in quality improvement initiatives to enhance the efficiency and effectiveness of the clinical review process
• Ensure compliance with established clinical guidelines, policies, and regulatory requirements
• Review and analyze medical records to assess the appropriateness and necessity of healthcare services
• Evaluate good faith estimates and “prebills” to determine scheduled care, including highlighting care that may not be included in the estimate (labs, radiology, pre-op visits, etc)
• Collaborate with healthcare providers to gather additional information when needed
• Drafts letters to send to members outlining benefits and other considerations
• Collaborate with provider team and Member care team to evaluate care shopping options
• 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

What You'll Bring

• Clinical credentials (RN)
• 5+ years of experience as a nurse providing direct patient care, preferably in a hospital setting
• 3+ years of utilization review experience, preferably in a health plan, managed care, or third-party administrator environment
• Hands-on experience using Milliman Care Guidelines (MCG)
• Medical billing and/or coding experience — this can be in a provider setting (billing, revenue cycle management, clinical auditing, legal compliance nurse) or payor setting (utilization management, prior auth review, payment integrity, etc.)
• 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
• Prior authorization experience (preferred)
• Bachelor's degree

What You'll Get

• Competitive salary, bonus opportunity, and equity package
• Comprehensive Medical, Dental, and Vision benefits
• A 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

Sidecar Health adopts a market-based approach to compensation, where base pay varies depending on location and is further influenced by job-related skills and experience. The current expected salary range for this position is $80,000 - $95,000.