Utilization Review Nurse

Capital District Physicians' Health Plan • Latham, NY

95d

About The Position

The Utilization Review (UR) Nurse is responsible for the clinical review and documentation for services requiring prior authorization. This includes approval determinations and appropriate exceptions, coordinating with Medical Directors on denials. In addition, the UR nurse is responsible for completing inpatient level of care reviews, post-acute care initial and concurrent reviews for acute and subacute rehabilitation, transportation, DME requests and inpatient readmissions. In collaboration with management, the UR nurse identifies potentially high-cost admissions and extended stays. The UR Nurse is also responsible for providing education to both internal and external constituents on nationally recognized criteria and CDPHP policies, and procedures.

Requirements

• Registered Nurse with a current New York State license required.
• Associates degree required.
• Minimum two (2) years of acute care experience as a Registered Nurse required.
• Minimum of two (2) years Utilization Management experience preferred.
• Knowledge of coding/claims processing preferred.
• Experience working with Microsoft Office, including Outlook, Word, and Excel required.
• Demonstrated ability to pro-actively identify problems and recommend solutions.
• Demonstrated ability to stay organized and work effectively within strict deadlines.
• Demonstrated ability to build relationships with providers, members, and community agencies.
• Demonstrated ability to provide excellent customer service.
• Demonstrated ability to review health care delivery against established criteria.
• Must be available after business hours for on-call rotations as needed.

Nice To Haves

• Utilization Management experience.
• Knowledge of coding/claims processing.

Responsibilities

• Conduct clinical review and documentation for services requiring prior authorization.
• Make approval determinations and coordinate with Medical Directors on denials.
• Complete inpatient level of care reviews and post-acute care initial and concurrent reviews.
• Review requests for acute and subacute rehabilitation, transportation, DME, and inpatient readmissions.
• Identify potentially high-cost admissions and extended stays in collaboration with management.
• Provide education to internal and external constituents on nationally recognized criteria and CDPHP policies.

Benefits

• Award-winning health care coverage.
• Health care dollars.
• Generous paid time off allowance.
• Employee assistance programs.
• Flexible work environment.
• Incentive payment based on performance.
• Potential for overtime pay.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Industry: Securities, Commodity Contracts, and Other Financial Investments and Related Activities
• Education Level: Associate degree
• Number of Employees: 501-1,000 employees