Remote Utilization Review Nurse Jobs in Oak Ridge, TN

Monogram Market Physician Executive (MPE) floats are mission driven physician leaders who are dedicated to improving the well-being, quality of life, and health outcomes for our patients. The MPE float will lead our in-home multi-specialty polychronic care model in an assigned region to support all markets. Each market is comprised of 5-10 practices led by local advanced practice providers (APP), registered nurses(RN), licensed clinical social workers (LCSW), and pharmacists (PharmD). The MPE Float will collaborate with Monogram Health’s Multi Specialty Platform to leverage employed specialists to deliver in-home specialty care. Monogram Health deploys a proven risk based model to ensure health equity and health equality leveraging proprietary next generation AI algorithms to predict the appropriate level of care. Aligning with the quadruple AIM, the MPE Float will focus to improve patient experience, population health outcomes, provider satisfaction and lower costs. The primary goal of each MPE Float to deliver exceptional outcomes through disease detection and evidence based clinical pathways and disease treatment.

Reporting to the Region President, the Market Physician Executive (MPE) float is a key clinical leader within Monogram Health who contributes to the development and oversight of clinical strategies, policies, programs, processes, protocols, guidelines, and operations that drive improved patient health outcomes within the market. The MPE - Float oversees the daily clinical and business operations through delivery of direct patient care, care management services, social worker support and pharmacy services within the market. In support of the advance practice providers the MPE Float is expected to review and approve care plans and direct the treatment plans for our patients. The MPE Float will collaborate with community physicians, facilities, and partners in peer to peer and direct patient care decision making.

• Know, understand, and deliver on Monogram Health’s proprietary evidenced based clinical pathways.
• Ensure adherence to established clinical guidelines and Monogram Model of Care.
• Review and approve APP, RN, SW and PharmD plans of care.
• Appropriate and timely patient document within Salesforce and Athena clinical activities, interventions, and tasks.
• Review, approve and co-sign APP encounters.
• Clinical and Operations Performance and Quality Improvement – 25%
• Overall accountability for reducing total cost of care and Medical Loss Ratio.
• Responsible for clinical outcomes to include, but not limited to, clinical interventions closure, inpatient/outpatient
• utilization, pharmacological prescribing and therapy management, multi-specialty platform and HEDIS/Gap Closure
• Actively lead daily high risk and concurrent review rounds.
• Direct supervision of front line clinical and operations team members.
• Oversee and delegate operational responsibility to Market Manager, to deliver on daily operations, such as patient engagement, scheduling, administrative oversight, strategic implementations, and P&L management.
• Regularly assess and present market performance and outcomes to Executive and Senior Leaders .

• Provide direct and indirect patient care (including diagnosis and treatment of disease).
• Engage with patients on treatment plans, community provider collaboration, and direct evidence-based care pathways.
• Conduct Peer to Peers with community, facility, and health plan partners.
• Order labs, referrals, and complete actions to drive patient outcomes, close care gaps, and Clinical Intervention closure.

• Provide clinical guidance and direction to Market teams to drive Population Health Management activities, including
• identifying and intervening on High-Risk Patients, formulating strategies to reduce admissions/readmissions, complete
• quality post hospital discharge visits, and improving the quality of visits.
• Collaborate with Medical Economics, Finance and other stakeholders to root cause and action against utilization trends impacting care and outcomes.
• Present and guide population health strategies in clinical and operational meetings.
• Conduct patient reviews to target high utilizers, high risk and high opportunity patients and patient cohorts.

• Participate in Monogram On-Call activities Needs will vary; 7 days on call minimum once/quarter.
• Provide coverage for other MPEs, during PTO or vacancy, as needed.

• Must be willing and able to obtain hospital privileges at required facilities.
• This position will be remote within the designated market with occasional in-home patient treatment visits and occasional domestic travel.
• Demonstrated experience applying evidence based clinical criteria.
• Experience in renal care and geriatrics.
• Strong management and communication skills.
• Active, unrestricted state medical license required in each state within the market.
• Experience with high need Medicare Advantage and managed Medicaid populations.
• Experience with NCQA, HEDIS, Medicaid, Medicare, quality improvement, medical utilization management, and risk adjustment.
• Current state medical license without restrictions to practice and free of sanctions from Medicaid or Medicare. Willingness to become licensed in multiple states.
• MD (Medical Doctor) or DO degree from an accredited medical school.
• BC or BE in an ACGME approved specialty such as Nephrology, Internal Medicine, Fam