Role Description Secures Patient-Centered Care: - Ensures the right care at the right time by validating medical necessity, advocating for benefits, and coordinating smooth, safe transitions to reduce readmissions. Maximizes Financial Health: - Protects and maximizes organizational revenue by preventing claim denials, ensuring proper status designation for reimbursement, and managing the appeals process. Drives Operational Efficiency: - Streamlines hospital workflows and the progression of care by coordinating with multidisciplinary teams and ensuring the responsible, judicious allocation of high-cost resources. Upholds Quality and Compliance: - Mitigates regulatory risk by enforcing evidence-based clinical standards (e.g., InterQual) and ensuring compliance with all governmental and third-party payer regulations. Qualifications - Registered Nurse credentialed from the Oklahoma Board of Nursing obtained prior to hire date or job transfer date required. - Diploma from an accredited school/college of nursing OR required professional licensure at time of hire. - 5+ years of Nursing experience preferred. - Case Management or Utilization Management experience preferred. Benefits - Paid time off (PTO) - Various health insurance options & wellness plans - Retirement benefits including employer match plans - Long-term & short-term disability - Employee assistance programs (EAP) - Parental leave & adoption assistance - Tuition reimbursement - Ways to give back to your community

Role Description - Performs concurrent inpatient utilization review using InterQual criteria to determine if the request meets medical necessity criteria, including: - Admission reviews - Continued stay reviews - Transitional care reviews (Skilled Nursing Facility, Inpatient Rehabilitation Facility, Long-Term Acute Care Hospital) - Related follow-up activities and documentation updates - Engages in clinical collaboration with attending physicians, hospitalists, and care teams to obtain clinical information, discuss medical necessity determinations, and support appropriate level-of-care decisions. - Capable of communicating clinical rationale to attending physicians, hospitalists, and facility staff during real-time concurrent review interactions. - Facilitates resolution of escalated cases that may require special handling. - Refers cases to a Physician Reviewer or to a Specialty Program Medical Director per guidelines. - Assists Physician Reviewers and Medical Directors, as necessary, to ensure compliance with review timeframes. - Maintains written documentation according to HealthHelp’s documentation policy. - Has a working knowledge of regulations, accreditation requirements, and payer-specific guidelines by state and market; applies InterQual level-of-care criteria and applicable HealthHelp or client medical policies to inpatient review determinations. - Adheres to all HIPAA, state, and federal regulations pertaining to the clinical programs. - Complies with URAC & NCQA standards or other requisite regulating bodies. - Ensures consistency in implementation of policy, procedure, and regulatory requirements in collaboration with Nursing Management. - Keeps current with regulation changes as provided by Compliance Department and Nursing Management. - Functions as subject matter expert to support Compliance Department initiatives and updates. - Collects and enters confidential information ensuring the highest level of confidentiality in all areas. - Performs clinical intake and reviews cases according to the policies and procedures of HealthHelp for markets and cases requiring expedited turnaround times. - Maintains availability to support concurrent review coverage requirements, which may include non-standard business hours, weekends, or holidays as determined by client contractual obligations and regulatory review timeframes. - Ability to perform multiple tasks simultaneously, prioritize projects, work independently under pressure, and meet critical deadlines. - Appropriately identifies and refers quality issues to UM Leadership. - Collaborates with client personnel to resolve customer concerns. - Provides quality customer service through interaction with providers, administrative staff, and others. - Creates, encourages, and supports an environment that fosters teamwork, respect, diversity, and cooperation with others. - Promotes business focus which demonstrates an understanding of the company’s vision, mission, and strategy. - Participates in the HealthHelp Quality Management Program, as required. - Performs other related duties and projects as assigned to meet business needs. Qualifications - RN graduate from an accredited school of nursing (BSN preferred). - Current, active unrestricted RN license in the state or territory of the U.S. (USRN equivalent). - Two (2) years of experience in an acute care setting, required. - Two (2) years of inpatient clinical nursing, utilization management, or case management experience, preferred. - Experience with InterQual or similar evidence-based clinical decision support criteria, preferred. - Willingness to complete and maintain InterQual certification and ongoing competency requirements. - Familiarity with inpatient level-of-care criteria, observation versus inpatient status determinations, and transitional care planning, preferred. - Working knowledge of medical necessity criteria, level-of-care determination standards, and payer-specific utilization review requirements. - Knowledge of insurance terminology. - Experience working with state and federal regulatory and compliance standards, preferred. - Proficient technical skills in Microsoft Office (Word, Excel, and PowerPoint), required. - Good organizational and time management skills. - Excellent written and verbal communication skills. - Ability to utilize critical thinking skills. - Highly motivated, self-starter who can work efficiently and independently, or as a team member. Benefits - Medical, dental, and vision insurance. - Paid time off (PTO), holidays, and sick leave. - 401(k) with company match or other retirement plan. - Life and AD&D Insurance. - Employee Assistance Program.

• Review medical records to determine the medical necessity of a request for medical services. • Validate diagnosis and corresponding algorithms of care. • Evaluate for over-utilization of treatment requests inconsistent with evidence based guidelines. • Communicate with the claims examiner, providers, and any other auxiliary provider regarding UR determination. • Summarize medical records and all pertinent information for Physician Advisor. • Identify the need for medical case management and make recommendations for referral through supervisor.

Role Description The Clinical Guide Part A will be part of the Utilization Management team, responsible for inpatient, behavioral health, and/or post-acute authorization review in alignment with CMS and Medicare Advantage regulations. - Reviews medical records to evaluate the medical necessity and appropriateness of requested inpatient and/or post-acute services in accordance with established clinical criteria and CMS guidelines. Your Responsibilities and Impact will include: - Review Medical Records: Conduct prospective (pre-service), concurrent, and retrospective utilization review to evaluate medical necessity, appropriate level of care (Inpatient vs. Observation), and post-acute services in accordance with established clinical criteria and CMS guidelines. - Evaluate Treatment Plans: Assess the appropriateness, timing, and setting of requested services, ensuring alignment with medical necessity criteria and Medicare Advantage requirements. Recommend alternative levels of care when clinically appropriate. - Inpatient & Behavioral Health Review: Perform initial, concurrent, and discharge reviews for inpatient and behavioral health admissions. Ensure admission status accuracy and regulatory compliance with CMS timeliness (TAT) standards. - Post-Acute Review: Conduct initial authorization and concurrent review for post-acute services (SNF, LTACH, ARU, Home Health), evaluating ongoing medical necessity and appropriate length of stay. Issue NOMNC when coverage criteria are no longer met. - Medical Director Collaboration: Refer cases that do not meet criteria to the Medical Director for secondary review and final determination. Prepare clinical summaries and coordinate peer-to-peer (P2P) discussions. Manage authorization reopen requests as appropriate. - Resource Stewardship: Monitor utilization of inpatient and post-acute services to promote appropriate resource use while maintaining high-quality, member-centered care. - Regulatory & Documentation Compliance: Maintain accurate, defensible documentation of all determinations. Ensure adherence to CMS regulations, Medicare Advantage requirements, and internal compliance standards. Qualifications - Unrestricted RN license with a minimum of 4 years of clinical experience. - Minimum 3 years of Utilization Management or Inpatient UR experience within a health plan or hospital setting. - Strong knowledge of CMS regulations and Medicare Advantage requirements. - Experience preparing cases for Medical Director review. - Able to work in a fast paced environment that is constantly evolving. Requirements - Experience with AI/LLM. - Certified in InterQual. Benefits - Employer sponsored health, dental and vision plan with low or no premium. - Generous paid time off. - $100 monthly mobile or internet stipend. - Stock options for all employees. - Bonus eligibility for all roles excluding Director and above; Commission eligibility for Sales roles. - Parental leave program. - 401K program. - And more....