Utilization Review Nurse

Village Care•New York, NY

11d•Remote

About The Position

VillageCare is looking for a self-motivated and passionate RN as Utilization Review Nurse for a Full-Time position. This is an exciting and dynamic position from the comfort of your own home as you will be responsible for the assessment of member needs and identification of solutions that promote high quality and cost effective health care services.

Requirements

Must reside within the New York Tri-State Area - NY, NJ, or CT.
Current unrestricted NYS RN license to practice professional nursing
BSN (advanced degree preferred)
2+ years of utilization review experience at a Managed Care Organization or Health Plan required.
Working knowledge of Medicaid and/or Medicare regulations as well as coverage guidelines and benefit limitations.
The ability to apply Interqual/ Milliman Care Guidelines and other applicable, evidenced-based clinical guidelines will be vital to this role.
Inpatient experience required.
MLTC and Hospital/SNF experience required.

Nice To Haves

URAC preferred

Responsibilities

Reviews planned, in process, or completed health care services to ensure medical necessity and effectiveness according to evidence-based criteria - prospective, concurrent and retrospective review.
Frequently collaborates and communicates with physician peer reviewers and medical directors in determining coverage of requested services.
Provide intervention and coordination to decrease delays and denials.
Maintains timely, complete and accurate documentation in compliance with VCMAX policies and procedures.
Support Quality and Performance Improvement Initiatives.
Timely follow-up on results of denial and internal appeal reviews.