Founded in 2007, The Oncology Institute of Hope and Innovation (TOI) is advancing oncology by delivering highly specialized, value-based cancer care in the community setting. TOI is dedicated to offering cutting edge, evidence-based cancer care to a population of more than 1.7 million patients including clinical trials, stem cell transplants, transfusions, and other care delivery models traditionally associated with the most advanced care delivery organizations. With 100+ employed clinicians and more than 700 teammates in 75+ clinic locations and growing. TOI is changing oncology for the better.

Reporting directly to the Chief Clinical Officer, the Utilization Management Nurse ("UM RN") is responsible for ensuring timely, high quality, and cost-effective therapeutic care to patients utilizing the TOI model in conjunction with our Mission, Vision, and Core Values. Your clinical care review determinations for our hematology and oncology patients will be instrumental in assuring patient access to life-saving care and supporting the value-based ideology of the practice.

Primary Job Responsibilities

Review cases for completeness of supporting documentation
Conduct pre-authorization review of services to ensure compliance with medical policy and contracts
With the UM Medical Directors, utilize evidence-based clinical guidelines to make utilization management decisions
Meet delivery timelines in notifying patients and providers of authorization decisions
Collaborate with nursing, eligibility, and authorization teams to facilitate continuity of care and optimal patient outcomes
Maintain accurate documentation of utilization and case management activities and report on those regularly
Adhere to practice policies and procedures, including compliance with HIPAA privacy and security requirements and all state, federal and plan regulatory mandates
Participate in quality improvement initiatives to enhance processes and service delivery
Participate in process improvement/cost of health care initiatives
Ensure workflow procedures and guidelines are clearly documented and communicated
Interpret or initiate changes in guidelines/policies/procedures
Collaborate across functionally to improve member outcomes
Participate in Regulatory and Internal Audits.

Required Knowledge, Skills, And Abilities

Strong verbal and written communication skills
Ability to work independently, initiate, and successfully complete tasks
Problem-solving aptitude and the ability to navigate challenging situations with sensitivity and professionalism
Excellent analytical and critical thinking skills with attention to detail for decision-making and problem-solving
Must be actively licensed, in good standing, by the appropriate regulatory body in the applicable state.
Mastery of computer skills, including Word, Excel, Power Point and applicable electronic medical software programs
Maintain regular attendance
Ability to effectively present information and respond to questions
Three (3) years of experience in utilization management

Fully remote position

The estimate displayed represents the typical wage range of candidates hired. Factors that may be used to determine your actual salary may include your specific skills, how many years of experience you have and comparison to other employees already in this role.

Pay Transparency for hourly teammates

$40—$48 USD

The Oncology Institute

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Utilization Review Nurse