Gender Affirming Services UM Nurse

AMIDA CARE INC.•New York, NY

6h•$77,014 - $96,284

About The Position

The Utilization Management (UM) Nurse for Gender Affirming Services (GAS) reviews and processes UM requests for gender affirming services in accordance with regulatory requirements, clinical guidelines, and established timeframes. The role partners with providers and members to support timely, appropriate, and member-centered care, and educates stakeholders about plan benefits, UM policies, and gender affirming services to support positive health outcomes.

Requirements

NYS Licensed Registered Nurse.
Two years of utilization management experience in a health plan setting.
Strong knowledge of Microsoft Office, including Access, Word, and Excel.
Demonstrated understanding and sensitivity to the multicultural values, beliefs, and attitudes of internal and external contacts.
Demonstrated behavior consistent with the organization’s vision, mission, and values.

Nice To Haves

Two years of experience working with the transgender community.
Knowledge of transgender surgical procedures.
Two years of health care or managed care experience.
Bilingual English/Spanish.

Responsibilities

Coordinate UM determinations with Clinical Services in accordance with Article 49-Utilization Review.
Complete UM activities in accordance with regulatory guidelines and timeframes.
Document UM activities in the appropriate database.
Work with the provider network to ensure current clinical guidelines are widely distributed.
Educate providers about plan benefits, UM policies, and clinical criteria.
Ensure pre- and post-surgery care coordination is member-driven and supports improved health outcomes, as applicable.
Educate members and providers about plan benefits, policies, and available support services.
Engage members and providers when a need is identified that could improve the behavioral or physical health of members of transgender experience.
When requested, review clinical documentation and claims or utilization data to ensure members are receiving appropriate care, and implement strategies to address unmet needs as appropriate.
Provide member education about gender affirming procedures, hormone treatment, and risk-reduction strategies, as appropriate.
Attend continuing education seminars and staff in-services, and stay current with relevant literature and trends in transgender services.
Protect member confidentiality and comply with confidentiality and HIPAA policies and regulations.