Utilization Management RN (Mostly Remote)

Vns Healthcare • New York, NY

449d • $85,000 - $106,300

About The Position

The position involves assessing member needs and identifying solutions to promote high-quality and cost-effective healthcare services. The role includes managing requests for medical services, rendering clinical determinations in accordance with healthcare policies, and coordinating with various stakeholders to ensure appropriate care delivery. The position operates under general supervision and requires a comprehensive review of service requests, compliance with regulations, and participation in case management activities.

Requirements

• Current license to practice as a Registered Professional Nurse or an Occupational Therapist in New York State required.
• Certified Case Manager preferred.
• Associate's Degree in Nursing or a Master's degree in Occupational Therapy required.
• Bachelor's Degree or Master's degree in nursing preferred.
• Minimum two years of experience in cost containment/case management or acute inpatient hospital experience in chronic or complex care required.
• Knowledge of working with the LTSS eligible population preferred.
• Knowledge of Medicare and Medicaid regulations required.
• Excellent organizational and time management skills.
• Strong interpersonal, verbal, and written communication skills.
• Working knowledge of Microsoft Excel, PowerPoint, and Word, and strong typing skills required.
• Knowledge of Milliman criteria (MCG) preferred.

Nice To Haves

• Experience with a Managed Care Organization or Health Plan for Utilization Management.
• Experience in Public Health programming, delivery, and evaluation for SelectHealth ETE.
• Experience working with community-based organizations in underserved communities preferred.

Responsibilities

• Conduct comprehensive reviews of service requests, including clinical record reviews and interviews with relevant parties.
• Examine standards and criteria to ensure medical necessity and appropriateness of admissions and treatments.
• Perform prior authorization and concurrent reviews to ensure medically necessary extended treatment.
• Ensure compliance with state and federal regulatory standards and VNS Health policies.
• Participate in case conferences with management.
• Identify opportunities for alternative care options and contribute to patient-focused care plans.
• Review covered services in accordance with established plan benefits and regulatory requirements.
• Provide recommendations for improvement regarding department processes and procedures.
• Maintain current knowledge of trends affecting member eligibility and determination notices.
• Improve clinical and cost-effective outcomes through member education and care management.
• Provide input for the design and development of effective member case management processes.
• Maintain accurate records of care management and progress notes according to guidelines.
• Participate in approval for out-of-network services when necessary.
• Provide case direction and assistance to ensure quality service delivery.
• Stay updated with health plan changes through ongoing training and educational materials.

Benefits

• Competitive salary range of $85,000.00 - $106,300.00 annually.
• Opportunities for professional development and training.
• Participation in case management conferences and collaboration with interdisciplinary teams.

What This Job Offers

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