Certified Nurse Practitioner, Utilization Management
Certified Nurse Practitioner, Utilization Management
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Job Description
About Curative:
Curative is creating the future of health insurance with its first-of-its-kind employer-based plan. Leveraging experience from leading the national COVID-19 testing effort Curative is now redefining health insurance through affordability engagement and simplicity. Their mission is to transform health insurance by eliminating financial barriers to care and guiding members at every step of their health journey offering a competitive monthly premium with zero additional costs* for in-network care. Curative envisions a future where nothing stands between members and the care they need focusing on a sustainable healthcare plan that makes it easy to actually achieve better health.
Job Summary:
We are seeking a highly motivated and experienced Certified Nurse Practitioner (CNP) to join our dynamic team at Curative. This critical role will be responsible for conducting utilization reviews prior authorization reviews and making medical necessity determinations for a variety of healthcare services. The ideal candidate will possess strong clinical knowledge excellent analytical skills and the ability to apply evidence-based guidelines and internal policies to ensure appropriate resource utilization while maintaining high-quality patient care. This is a remote-friendly position but candidates must be licensed in Texas Florida and Georgia.
Key Responsibilities:
Perform comprehensive utilization reviews (prospective concurrent and retrospective) for medical surgical and other healthcare services.
Conduct thorough prior authorization reviews based on established clinical criteria medical policies and contractual agreements.
Evaluate medical records clinical documentation and other relevant information to assess medical necessity.
Apply evidence-based guidelines nationally recognized standards of care and company medical policies to render medical necessity determinations.
Issue medical necessity denials when appropriate providing clear and concise rationales in accordance with regulatory requirements.
Collaborate effectively with providers members and internal teams to gather necessary information and communicate decisions.
Participate in interdisciplinary team meetings and contribute to the development and refinement of utilization management processes and policies.
Maintain accurate and timely documentation of all review activities in the designated systems.
Stay current with healthcare trends regulatory changes and clinical guidelines relevant to utilization management.
Adhere to all HIPAA regulations and maintain patient confidentiality.
Qualifications:
Active and unrestricted Certified Nurse Practitioner (CNP) license in Texas (TX) Florida (FL) and Georgia (GA) is required.
Masters or Doctor of Nursing Practice (MSN/DNP) degree from an accredited program.
Minimum of 3-5 years of clinical experience as a Nurse Practitioner.
Proven experience in utilization review prior authorizations and/or medical necessity determinations within an insurance or managed care setting.
Strong understanding of healthcare delivery systems CPT/ICD-10 coding and medical terminology.
Excellent analytical critical thinking and decision-making skills.
Exceptional written and verbal communication skills with the ability to articulate complex medical information clearly and concisely.
Proficient in using electronic health records (EHR) and utilization management software.
Ability to work independently and manage a high volume of cases effectively in a fast-paced startup environment.
Demonstrated commitment to ethical practice and compliance with all relevant regulations.
Strong interpersonal skills and the ability to collaborate effectively with diverse stakeholders.
Preferred Qualifications:
Experience with NCQA URAC or other accreditation standards.
Certification in Case Management or Utilization Management.
Benefits:
Competitive annual salary of $105000 plus 20% bonus potential
Opportunity to be a foundational member of a rapidly growing startup that is transforming health insurance.
e.g. comprehensive health dental and vision insurance paid time off 401(k) or retirement plan professional development opportunities.
Employment Details:
This position is subject to a 120-day trial employment period.
Required Experience:
IC
Employment Type
Full-Time
