Utilization Management Reviewer, RN (SN LTSS & Duals)

company•City of Utica, NY

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. It ensures compliance with internal and external regulatory and accreditation standards, 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 require additional hours based on departmental needs. The reviewer performs pre-service, concurrent, and post-service clinical reviews to assess the appropriateness and medical necessity of requested services. Reviews apply clinical criteria, medical policies, contractual benefits, and state and federal mandates, and may be conducted by phone, electronically, or on-site. The position documents utilization management activities, communicates with members and providers, collaborates with other care providers to support continuity of care, and meets timeliness, production, audit, and compliance requirements. The job includes three levels of responsibility. Higher levels take on more complex and independent assignments, contribute to process improvement, mentor and train staff, serve as subject matter experts, support escalations, and provide leadership. Level III may provide backup for the Supervisor and assist the Medical Director with projects. The position may require travel across health plan service regions and prolonged computer use.

Requirements

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

Nice To Haves

Bachelor's degree.
Utilization Management experience.
Experience interpreting managed care benefit plans.
Strong knowledge of Medicare and Medicaid program contracts and benefits.

Responsibilities

Perform pre-service, concurrent, and post-service clinical reviews to determine 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 while complying 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 avoid gaps in care.
Serve as a resource and liaison to providers regarding health plan medical review processes, 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 assigned, price, code, or research claims to ensure accurate application of contract benefits and corporate medical policies.
Meet departmental timeliness, production, metric, and audit requirements.
Maintain compliance with regulatory and accrediting standards and monitor and implement applicable changes.
Assist with training and special projects as assigned.
Protect member privacy and uphold corporate policies, the Code of Conduct, and company values.
Maintain regular and reliable attendance and perform other functions assigned by management.
At Level II, offer process improvement suggestions, help resolve complex issues, mentor staff, collaborate independently with members and providers, manage complex assignments, cross-train across levels of care or services, and participate in or lead committees when required.
At Level III, identify and assess process improvements, assist in updating policies and procedures, serve as a subject matter expert for escalations, guide staff, participate in staff orientation and training, help staff engage members in care, provide backup for the Supervisor when necessary, and assist the Medical Director with projects.
Travel across health plan service regions as needed.