Qureos Mentor

American Health Partners

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 This position is a hybrid, on-site role in Franklin, TN!
 
 
 
 American Health Plans, a division of Franklin, Tennessee-based American Health Partners Inc. owns and operates Institutional Special Needs Plans (I-SNPs) for seniors who reside in long-term care facilities. In partnership with nursing home operators, these Medicare Advantage plans manage medical risk by improving patient care to reduce emergency room visits and avoidable hospitalizations. This division currently operates in Tennessee, Georgia, Missouri, Kansas, Oklahoma, Utah, Texas, Mississippi, Iowa, Idaho, Louisiana, and Indiana with planned expansion into other states in 2025. For more information, visit
 
 
 
 AmHealthPlans.com
 
 
 
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 If you would like to be part of a collaborative, supportive and caring team, we look forward to receiving your application!
 
 
 
 Benefits And Perks Include
 
 
 
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 Affordable Medical/Dental/Vision insurance options
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 Generous paid time-off program and paid holidays for full time staff
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 TeleDoc 24/7/365 access to doctors
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 Optional short- and long-term disability plans
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 Employee Assistance Plan (EAP)
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 401K retirement accounts with company match
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 Employee Referral Bonus Program
 
 
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 Job Summary
 
 
 
 The Utilization Review Nurse is to assess the medical necessity and quality of healthcare services by conducting pre-service, concurrent, and retrospective utilization management reviews. The primary role of the Utilization Management (UM) Nurse is to provide clinical support to the Clinical Services Department and Medical Director to assure that members receive all appropriate medical services in compliance with medical and regulatory guidelines.
 
 
 
 Essential Job Duties
 
 
 
 To perform this job, an individual must accomplish each essential function satisfactorily, with or without a reasonable accommodation.
 
 
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 Assess the medical necessity, quality of care, level of care and appropriateness of health care services for plan members
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 Identify placement settings that offer the lowest level of restriction and greatest level of autonomy for the members based upon medical necessity
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 Conduct outreach to requesting providers which can include specialty physicians, ancillary providers and institutions to gather the appropriate/necessary clinical data
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 Apply clinical review criteria, guidelines, and screens in determining the medical necessity of health care services against the clinical data provided
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 Certify cases that meet clinical review criteria, guidelines and/or screens
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 Consult with physician when reviews do not meet clinical review criteria, guidelines, and screens
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 Refer cases to other professionals internally, including case management and medical consultation when indicated
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 Adhere to accreditation, contractual and regulatory timeframes in performing all utilization management review processes
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 Ensure that the Director of Medical Management or designee is made aware of any potential risk management issues in a timely manner
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 Other duties as assigned
 
 
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 Job Requirements
 
 
 
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 Maintain privacy and confidentiality of records, conditions, and other information relating to residents, employees and facility
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 Encourage an atmosphere of optimism, warmth and interest in patients&rsquo; personal and health care needs
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 Develop and maintain collaborative relationships with providers and educate on levels of care
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 Ensure the integrity and high quality of utilization management services
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 Self-motivated
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 Ability to work independently and as part of a team
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 Able to work congenially with a wide variety of individuals
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 Maintain the highest level of confidentiality and professionalism at all times
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 Strong oral and written communications skills, including active listening
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 Proficient in navigating through multiple computer applications
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 Positive, engaging customer service skills
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 Critical thinking and decision-making skills
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 Successful completion of required training
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 Handle multiple priorities effectively
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 Independent discretion/decision making
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 Make decisions under pressure
 
 
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 Required Qualifications
 
 
 
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 Experience:
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 At least 1 year experience in utilization management with a health plan or hospital-based UM department with use of Interqual or MCG
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 Prefer clinical experience
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 Broad knowledge of Medicare regulations and guidance
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 Trained in clinical certification, utilization management, URAC and NCQA principles, policies, and procedures
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 Excellent customer service experience
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 Strong knowledge of medical terminology and CPT, ICD-10, and HCPCS codes
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 Proven ability to problem-solve and make solid decisions
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 License/Certification:
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 Current Certified Case Manager (CCM) credential is a plus
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 Current, active and unrestricted Registered Nurse (RN) license
 
 
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 EQUAL OPPORTUNITY EMPLOYER
 
 
 
 
 This Organization is an equal opportunity employer. We do not discriminate based on race, color, religion, sex, handicap, disability, age, marital status, sexual orientation, national origin, veteran status, or any other characteristic(s) protected by federal, state, and local laws. This Organization will make reasonable accommodations for qualified individuals with disabilities should a request for an accommodation be made. A key part of this policy is to provide equal employment opportunity regarding all terms and conditions of employment and in all aspects of a person's relationship with the Organization including recruitment, hiring, promotions, upgrading positions, conditions of employment, compensation, training, benefits, transfers, discipline, and termination of employment.
 
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Utilization Review Nurse

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 Recruiting Coordinator
 
 
 
 
 Job Summary
 
 
 
 The Recruiting Coordinator plays a vital role in supporting the recruiting function by maintaining organized documentation, ensuring compliance, assisting with sourcing activities, and coordinating a seamless onboarding experience for new hires. This position is key to the operational success of the recruiting team, working closely with recruiters, HR, and hiring managers to deliver an efficient and professional candidate-to-employee transition. The ideal candidate is detail-oriented, highly organized, and skilled at balancing multiple priorities in a fast-paced environment.
 
 
 
 Essential Job Duties
 
 
 
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 Coordinate pre-employment screenings, background checks, and new hire paperwork to ensure compliance with company, state, and federal regulations.
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 Assist in preparing offer and onboarding materials; coordinate orientation sessions and ensure all required forms are completed accurately and on time.
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 Maintain accurate and confidential recruiting and personnel documentation in accordance with company policies.
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 Build and maintain relationships with hiring managers, providing updates and support on onboarding activities and documentation.
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 Partner with internal teams to identify process improvements and enhance the overall onboarding experience.
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 Track and report on recruiting and onboarding metrics to identify trends and improve efficiency.
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 Support HR and recruiting compliance efforts by maintaining organized files, monitoring deadlines, and ensuring accurate data entry in ATS and HR systems.
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 Assist recruiters with sourcing activities such as posting job ads, screening resumes, and maintaining candidate pipelines as needed.
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 Serve as a liaison between HR, Facilities, and other departments to coordinate new hire logistics and ensure a smooth day-one experience.
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 Support HR Operations and Recruiting by coordinating projects and assisting with miscellaneous departmental initiatives as needed.
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 Perform other duties as assigned to support recruiting and HR operations.
 
 
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 Job Requirements
 
 
 
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 Strong communication, interpersonal, and organizational skills with a focus on accuracy and attention to detail.
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 Ability to manage multiple priorities and maintain confidentiality.
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 Demonstrated ability to work collaboratively with internal teams and new hires.
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 Proficiency in Microsoft 365 (Outlook, Excel, Word, Teams, SharePoint, and related applications) is required.
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 Experience with HR-related systems such as applicant tracking systems (ATS) and HRIS platforms (UltiPro/UKG) preferred.
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 Functions in a professional, courteous, and responsive manner with employees, candidates, and external partners.
 
 
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 Required Qualifications
 
 
 
 
 Education
 
 
 
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 High school diploma or equivalent required.
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 Associate or Bachelor&rsquo;s degree in human resources, Business Administration, or related field preferred.
 
 
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 Experience
 
 
 
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 Minimum of 1&ndash;2 years of experience in HR, recruiting, or onboarding support roles.
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 Experience coordinating onboarding or compliance-related tasks preferred.
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 Familiarity with sourcing tools and recruiting workflows a plus.
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Healthcare Recruiting Coordinator

Join American Health Partners and explore 2   exciting career opportunities. They're hiring for various roles with options for remote or on-site work. Apply today and become part of their innovative team.

American Health Partners

ABOUT_COMPANY

Utilization Review Nurse

Healthcare Recruiting Coordinator