Utilization Management Reviewer, RN (SN LTSS & Duals)

Excellus BCBS • De Witt, AR

7d • $62,400 - $117,622

About The Position

This position coordinates, integrates, and monitors the utilization of physical health medical and healthcare services for members, ensuring compliance with internal and external regulatory and accreditation standards. The reviewer refers appropriate cases to the Medical Director and works closely with Case Management to address member needs. The role participates in a rotating on-call schedule as required and may work additional hours based on department needs.

Responsibilities vary by classification level. Level I performs pre-service, concurrent, and post-service clinical reviews using established clinical criteria, guidelines, medical policies, contractual benefits, and State and Federal mandates. Reviews may be conducted by telephone, electronically, or on-site. The reviewer plans and documents utilization management activities, assesses medical necessity, communicates with members and providers, supports access to needed care, collaborates with care providers to prevent gaps in care, and serves as a resource and liaison to the provider community. The role may also involve pricing, coding, and claims research; meeting timeliness, production, and audit requirements; monitoring regulatory changes; and assisting with training and projects.

Level II adds process-improvement work, mentoring and coaching, handling more complex assignments, reviewing multiple levels of care or services, collaborating independently with members and providers, and participating in or leading committees. Level III adds departmental leadership, identification and assessment of process improvements, policy and procedure updates, subject-matter expertise for escalations, mentorship and guidance to clinical staff, support for staff orientation and training, backup for the Supervisor, and assistance to the Medical Director on projects.

The position requires an associate degree and an active New York State RN license. A bachelor’s degree is preferred. Candidates must have at least three years of clinical experience, proficiency with Microsoft Office, a general understanding of coding standards, current working knowledge of Utilization Management standards, strong communication skills, the ability to multitask and work independently, and the ability to deliver efficient and seamless care to members. Utilization Management experience and knowledge of managed-care benefits and Medicare and Medicaid contracts are preferred. Higher classification levels require additional Utilization Management experience and broader expertise, as detailed in the qualifications.

Requirements

• Associate degree required.
• Active New York State RN license required.
• At least three years of clinical experience required.
• Proficiency with the Microsoft Office Suite.
• General understanding of coding standards.
• Current working knowledge of Utilization Management standards.
• Strong written and verbal communication skills.
• Ability to multitask and balance priorities.
• Ability to work independently on a daily basis.
• Ability to deliver efficient, effective, and seamless care to members.
• Ability to travel across health plan service regions as needed.
• Ability to work at a computer for prolonged periods.
• Level II: At least two years in a Utilization Management position.
• Level II: Ability to escalate issues to management as necessary, proficiency in related technology, ability to take on broader responsibilities, and ability to participate in training new staff.
• Level III: At least five years in a Utilization Management position or a similar subject-matter-expert role.
• Level III: Broad understanding of multiple functional areas, such as Utilization Management and Case Management, and supporting systems.
• Level III: Expertise in Utilization Management and ability to handle complex assignments, challenging situations, and highly visible issues.
• Level III: Ability to lead training for new staff and demonstrated presentation skills.

Nice To Haves

• Bachelor’s degree preferred.
• Utilization Management experience preferred for all levels.
• Experience interpreting managed-care benefit plans and strong knowledge of Medicare and Medicaid government program contracts and benefits preferred.

Responsibilities

• Conduct pre-service, concurrent, and post-service clinical reviews to assess the appropriateness and medical necessity of requested services.
• Apply clinical review criteria, guidelines, medical policies, contractual benefits, and State and Federal mandates.
• Plan, implement, and document utilization management activities in compliance with corporate and departmental policies and procedures.
• Identify and refer potential quality-of-care and utilization issues to the Medical Director.
• Communicate with members and providers to obtain clinical information, assess medical necessity, and support members in obtaining needed services.
• Collaborate with hospitals, home care, care management, and other providers to meet clinical needs and prevent gaps in care.
• Act as a resource and liaison to providers regarding Health Plan medical review, case or disease management support, and other programs and services.
• Interpret clinical criteria, medical policy, contract benefits, and State and Federal mandates accurately and consistently.
• As needed, price, code, and research claims to ensure accurate application of contract benefits and Corporate Medical Policies.
• Meet departmental timeliness, production, metrics, and audit requirements.
• Maintain compliance with regulatory and accrediting standards and monitor and implement applicable changes.
• Assist with training and special projects as assigned.
• Maintain member privacy and adhere to the Corporate Code of Conduct and company values.
• Participate in a rotating on-call schedule as required and work additional hours as department needs dictate.
• At Level II, suggest process improvements, help resolve complex issues, mentor and coach staff, manage complex assignments, review multiple levels of care or services, and participate in or lead committees.
• At Level III, identify and assess productivity and efficiency improvements; update departmental policies and procedures; serve as a subject-matter expert for escalations; mentor and guide clinical staff; support staff orientation and training; provide backup for the Supervisor; and assist the Medical Director with projects.
• Travel across health plan service regions as needed.

Benefits

• Group health and/or dental insurance may be included in the total rewards package.
• Retirement plan may be included in the total rewards package.
• Wellness program may be included in the total rewards package.
• Paid time away from work may be included in the total rewards package.
• Paid holidays may be included in the total rewards package.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: Associate degree