Nurse Case Manager, Granular

Who We Are

Verily is a subsidiary of Alphabet that is using a data-driven approach to change the way people manage their health and the way healthcare is delivered. Launched from Google X in 2015, our purpose is to bring the promise of precision health to everyone, every day. We are focused on generating and activating data from a variety of sources, including clinical, social, behavioral and the real world, to arrive at the best solutions for a person based on a comprehensive view of the evidence. Our unique expertise and capabilities in technology, data science and healthcare enable the entire healthcare ecosystem to drive better health outcomes.

Description

The ideal candidate will work closely with Granular’s Medical Director of Cost Management (MD) to identify, quantify and implement cost saving opportunities for Granular stop loss business. As part of Granular’s Health & Risk Solutions team, the candidate will assess medical risk for each identified claimant utilizing all available information, and apply appropriate guidelines to meet the financial risk management goals of the company. In addition, the candidate will be responsible for reviewing detailed large claim reports from a variety of sources including trigger reports, detailed individual claim reports, pending and denied reports, case management reports, and utilization reports.

Responsibilities

• Analyzes detailed claim data, including medical procedure codes, specialty pharmacy codes, facility based codes and other relevant codes to assist in identifying billing abuses and predicting future claim costs.
• Researches rare/complicated medical conditions/treatment options using resources including the MD, internet, and clinical resource tools by state/network. Stays informed of current medical trends, particularly in the areas of specialty pharmacy, cell and gene therapy. 
• Presents and documents a clear medical review summary with an analysis of the current clinical conditions and suggestions on how to manage costs more effectively. 
• Assists with the initial communication to TPA, case management company or vendor partner of opportunities and strategies to mitigate overpriced claims. Schedules follow up communication (phone calls or emails) with the same stakeholders to affect the cost saving measures that have been identified in the medical record review process. 
• Assists the MD in the development of key operations processes and direct implementation of such processes within the company or with external partners and clients.

Qualifications

Minimum Qualifications: 

• Registered Nurse (RN) and Bachelor’s Degree in Nursing or related clinical field.
• Three (3) years direct clinical experience, preferably in acute care and four (4) years’ experience in medical case management, utilization review, etc.
• Knowledge of ICD 10 coding and medical terminology.
• Excellent verbal and written communication skills and the ability to simplify complex concepts for varying levels of audiences.
• Demonstrated understanding of the health insurance operational and administrative flow.

Preferred Qualifications:

• Bilingual (English and Spanish or French).
• Experience with a startup company.
• Excellent project management skills.
• Creative and analytical thinking with strong problem-solving skills.

#LI-Remote #LI-KK1

The US base salary range for this full-time position is $100,000-$120,000 + bonus + benefits. Our salary ranges are determined by role, level and location. The range displayed on each job posting reflects the minimum and maximum target for new hire salaries for the position across all US locations. Within the range, individual pay is determined by work location and additional factors, including job-related skills, experience, and relevant education or training. Your recruiter can share more about the specific salary range for your preferred location during the hiring process.

Please note that the compensation details listed in US role postings reflect the base salary only, and do not include bonus, equity or benefits.

Why Join Us

Build What’s Vital.

At Verily, you are a part of something bigger. We are a diverse team of builders innovating at the intersection of health and technology—united by a shared spirit of curiosity, resilience and determination to make better health possible for all. This builder mindset means your fingerprints will be on the work that shapes the future of health. 

Fulfilling our precision health purpose starts with the health of our Veeps, which is why we offer flexibility, resources, and competitive benefits to support you in your whole-person well being. 

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