Utilization & Care Management Nurse na Verda Healthcare Inc

Description

Verda Health Plan of Texas has a contract with the Center of Medicaid and Medicare Services (CMS) and a state license with the Texas Department of Insurance for a Medicare Advantage Prescription Drug (MAPD) plan. We are committed to the idea that healthcare should be easily and equitably accessed by all. Our mission is to ensure that underserved communities have access to health and wellness services, and receive the support needed to live a healthy life that is free of worry and full of joy. We are looking for a Utilization & Care Management Nurse to join our growing company with many internal opportunities.

Are you ready to join a company that is changing the face of health care across the nation? Verda Healthcare plan is looking for people like you who value excellence, integrity, care and innovation. As an employee, you’ll join a team dedicated to improving the lives of our Medicare members. Our vision incorporates value-based health care that works. We value diversity.

Align your career goals with Verda Healthcare, Inc. and we will support you all the way.

Position Overview
This position Utilization & Care Management Nurse plays a key role in ensuring members receive appropriate, high-quality, and cost-effective care. This position is responsible for assessing medical necessity, coordinating care, and supporting members throughout the continuous care while maintaining compliance with regulatory and organizational standards. The nurse will work collaboratively with physicians, providers, interdisciplinary care teams, and members to promote optimal health outcomes and resource utilization. The UM/CM Nurse will conduct utilization review activities, including prior authorizations, concurrent review, and retrospective review of medical services as well as support care management functions such as care planning, coordination of services, transition of care, and member education. The role requires sound clinical judgment, strong communication skills, and a thorough understanding of Medicare guidelines, clinical criteria, and managed care principles.

This position reports to Sr. Manager, Utilization & Care Management Nurse.

Responsibilities:

Utilization Management (UM):

· Review and evaluate inpatient admissions, observation status, pharmacy service requests, and other clinical service requests submitted by Verda’s delegates to ensure appropriateness based on CMS guidelines, evidence-based criteria (e.g., InterQual, MCG), and organizational protocols.

· Serve as the clinical escalation point for complex UM cases, including grievances, appeals, denials, and high-cost or high-risk pharmacy requests.

· Conduct audits of the full UM lifecycle across IPAs, including intake, authorization creation, clinical review, and determinations, ensuring documentation is accurate, timely, and compliant with regulatory standards.

· Monitor utilization data, pharmacy trends, and key performance indicators to identify patterns, address inefficiencies, and inform strategic decision-making.

· Collaborate with Pharmacy, Claims, Enrollment, Member Experience, and other internal departments to support integrated operations and care delivery.

· Develop and implement corrective action plans and quality improvement initiatives to improve performance, compliance, and operational efficiency.

· Contribute to the development and maintenance of UM and pharmacy-related workflows, policies, procedures, and audit tools. 

Care Management (CM):

· Conduct comprehensive member care reviews in coordination with IPAs and medical groups to ensure appropriate care planning and service delivery.

· Develop and maintain individualized care plans (ICPs) based on Health Risk Assessment (HRA) outcomes and participation in Interdisciplinary Care Team (ICT) meetings.

· Identify high-risk or complex members and escalate cases to leadership for additional oversight or intervention, ensuring alignment with clinical guidelines and medical necessity.

· Provide oversight and support for end-to-end care coordination activities performed by IPAs, including discharge planning, transitions of care, and interdisciplinary case management.

· Integrate pharmacy data and medication reviews into care planning to address adherence and cost-effective prescribing.

· Participate in interdepartmental case conferences and workgroups to improve care management strategies and member outcomes.

· Assist in the development and implementation of care management goals, initiatives, and process improvements in accordance with organizational priorities.

Requirements

Minimum Qualifications: 

· Minimum of 3 years of managed care experience in inpatient/outpatient care, utilization review, or pharmacy review within a health plan or similar environment.

· At least 5 years of clinical experience in nursing, healthcare, or a related field.

· Strong knowledge of CMS regulations, clinical review tools (e.g., InterQual, MCG), and formulary management.

· Understanding of medical coding (ICD-10, CPT/HCPCS) and pharmacy benefit management.

· Experience with care coordination, chronic condition management, and evidence-based practice guidelines.

· Strong analytical, organizational, and time management skills with the ability to multitask in a fast-paced environment. 

Licensure/Certification:

· Active, unrestricted RN or LVN license required.

· Certification in Case Management (CCM) or Utilization Review preferred but not required.

Verda cares deeply about the future, growth, and well-being of its employees. Join our team today!

Job Type: Full-time

Benefits:

• 401(k)
• Paid time off (vacation, holiday, sick leave)
• Health insurance 
• Dental Insurance
• Vision insurance 
• Life insurance

Schedule:

• Full-time onsite (100% in-office)
• Hours of operations: 9am – 6pm
• Standard business hours Monday to Friday/weekends as needed
• Occasional travel may be required for meetings and training sessions.

Ability to commute/relocate:

• Reliably commute or planning to relocate before starting work (Required)

PHYSICAL DEMANDS

Regularly sit/walk at a workstation in an office or cubicle setting. Must occasionally lift and/or move up to 25-50 pounds.

*Other duties may be assigned in support of departmental goals.