We are… an employee health & benefits company with a tech-meets-service platform that simplifies and personalizes how employees and employers shop, enroll and live with their benefits. Our innovative technology makes it easy for employees to choose the right benefits plan while equipping HR with the tools they need through one partner, one service team, one platform, one portal.

Maestronites are… brought together with a passion to disrupt the status quo by reimagining employee health and benefits.  This passion has driven us to create the first complete platform that optimizes the entire benefits experience for everyone.  Our people, passion and platform are united by our mission: to make employee health & benefits people-friendly again.

WHAT YOU WILL BE DOING:

Performs utilization review in accordance with DOL/ERISA guidelines as well as any applicable state mandates.  Maintains compliance with regulation changes affecting utilization management.  Responsible for accepting and reviewing all physician and other health care provider requests, as well as consumers' requests, for treatment and utilizing approved screening medical necessity criteria Maestro Health (MH) utilizes MCG (Milliman Guidelines) as the principle criteria set to determine medical necessity and initial length of authorization.  Refers to the Independent Review Organization (IRO) any case where screening by the nurse does not meet medical necessity criteria and ensures a timely decision is rendered by the Peer Reviewer.  Ensures all notifications are made according to policy and conducted with established timeframes.  References health plan information as appropriate to ensure the consumer falls under the MH Utilization Review Program.  Refers cases as appropriate for screening by the MH Case Management or Population Health Management Programs. 

• RECEIVE AND REVIEW WRITTEN AND VERBAL REQUESTS FROM PROVIDERS (or contact providers when request is initiated by the consumer) and screen against approved criteria to certify the requested service;
• Contact providers as needed to obtain relevant clinical information to support the medical necessity or requested services;
• Document all required elements in the MH system to support the certification of the service
• DEMONSTRATE SOUND CLINICAL KNOWLEDGE OF DISEASE STATES AS WELL AS GOOD UNDERSTANDING OF DISCHARGE NEEDS OF PATIENTS
• Refer cases that fall outside the nurse's screening guidelines to the Peer Review Organization/Independent Review Organizations(s) contracted by MH to conduct peer reviews so that the determination regarding medical necessity and plan benefit/language coverage is made by an appropriate physician peer reviewer; UR nurse with MH will state and specialty match; will ensure peer and attending talk (attempts x 2) if non-certification being considered
• COORDINATE ALL REFERRALS FOR PHYSICIAN REVIEWS to ensure all time frames for timely decisions are met and that documentation of rationale and supporting evidence for decision is documented according to policy
• Identify opportunities to manage utilization and refers to case management or population health management as plan benefits allow
• Perform research to determine if the plan covers the requested services and if the requested services meet plan requirements
• Ensure all timeframes are met for notifications of decisions
• Ensure appeal rights are given per policy for all noncertifications
• Interact and communicate telephonically in a professional manner, striving for continuity and efficiency as the member is managed along the continuum of care;
• UNDERSTAND FISCAL ACCOUNTABILITY AND ITS IMPACT ON RESOURCES
• Identify, monitor and evaluate serious potential quality issues, and notifies the Director of Medical Management for assistance on how to handle these issues
• Evaluate health care services offered and provided by members of the health care team, analyze variances according to evidence-based clinical practice guidelines, and participate in the quality improvement processes to enhance and improve MH services and member outcomes
• Demonstrate sensitivity to culturally diverse situations, clients and customers
• Provide quality, cost effective UR services for members
• ENSURES DOCUMENTATION IN THE MEDWEB SYSTEM MEETS ESTABLISHED STANDARDS, and that cases are appropriately opened and closed in the UR system
• Support training initiatives as assigned by Maestro Health; assimilates any newly established procedures and processes as identified by employer group and implemented by MH
• Demonstrates awareness of risk management issues and alerts the appropriate MH and Compliance staff

WHAT SUCCESS LOOKS LIKE:

• Proficient and independent utilizing Milliman Care Guidelines (MCG) with 90 – 95% accuracy
• Demonstrates the ability to document pertinent clinical information concisely with 90-95% accuracy
• Proficient with Medweb/Outlook/WLT/Ring Central/Deerwalk/S drive/on-line medical management manual/resources  
• Proficient with process tasks, including:  referrals to peer review, Claim Doc, AMPS and network verification
• You are recognized for one of our core values: Fun. Preparedness. Teamwork. Humility. Urgency. Bold Thought. Honesty.
  • RNC – any area is acceptable

WHAT YOU NEED:

• A license to practice as a Licensed Practical Nurse or Registered Nurse, and 3 years' clinical practice experience; (RN is preferred)

• Certification is preferable in an area related to Health Utilization Management. The following certifications will be accepted:

  • CCM – Certified Case Manager (preferred)
  • CPHM – Certified Professional in Health Management
  • CRRN – Certified Registered Rehabilitation Nurse
  • RNCm – Nurse Case Manager

• CHCQM – Certified in Health Care Quality Management (ABQAURP)

• ACCC – Advanced Competency Certification in Continuity of Care

1-3 years of utilization review or case management experience preferred

Knowledge of State of licensure's Scope of Nursing Practice

Knowledge of state/federal requirements for Utilization Management/Case Management

Excellent time management, organization, prioritization, research, analytical, negotiation, communication (oral and written) and interpersonal skills.

Employ analytical thinking and commit to quality case management and healthcare service(s)

Perform duties in an ethical manner and work with a cross functional team

Understand business management theory and practices; prioritize, analyze, and negotiate multidirectional communication for consensus

Efficient ability to multi-task and prioritize critical objectives throughout the day;

WHY WORK AT MAESTRO HEALTH?

We have great benefits:

• Personal, Vacation and Sick Time
• Medical and Prescription
• Dental
• Vision
• Life and Disability
• Health and Wellness programs
• 401k with Employee Match
• Kashable
• Figo – Pet Insurance

We have great perks in each of our offices, along with a fun, energetic and fast-paced environment, and WHAT WILL REALLY DRIVE YOU IS OUR VISION. Maestro Health is making employee health & benefits people-friendly again by making healthcare easy to understand, tools easy to use, and costs easy to control. We are aiming to become a household name within the employee health & benefits space.

We can't do that without great people. We want to hear “WOW! That was the best job and business experience I ever had!” from every Maestronite – past, present, and future. You should be personally challenged, laugh, work your tail off and look forward to coming to work.

ARE YOU READY TO BECOME A MAESTRONITE? LET'S DO THIS.

Maestro Health is an equal opportunity workplace.  We are committed to equal opportunity regardless of race, color, religion, sex, national origin, sexual orientation, age, citizenship, marital status, disability, or veteran status.