Job Description
Job Description: Utilization Management Nurse Work Location: Remote based. Candidates can be located anywhere in the US but must be licensed in NY State. Will now accept RNs!
No Compact Licenses as State of NY requires a NY license, but you can live anywhere in the USA with active NY License
Pay: $40.00 per hour - benefit plan offered.
Job Summary: The Utilization Management Nurse will work with the Utilization Management team primarily responsible for inpatient medical necessity/utilization review and other utilization management activities aimed at providing large MCO members with the right care at the right place at the right time. This role involves daily review and evaluation of members that require hospitalization and/or procedures, providing prior authorizations and/or concurrent review, and assessing services to ensure optimum outcomes, cost-effectiveness, and compliance with all state and federal regulations and guidelines.
Essential Functions: - Provide concurrent review and prior authorizations (as needed) according to large MCO policy for members as part of the Utilization Management team.
- Identify appropriate benefits, eligibility, and expected length of stay for members requesting treatments and/or procedures.
- Participate in interdepartmental integration and collaboration to enhance the continuity of care for members, including Behavioral Health and Long-Term Care.
- Maintain department productivity and quality measures.
- Attend regular staff meetings.
- Assist with mentoring new team members.
- Complete assigned work plan objectives and projects on a timely basis.
- Maintain professional relationships with the provider community and internal and external customers.
- Conduct self in a professional manner at all times.
- Maintain cooperative and effective workplace relationships and adhere to company Code of Conduct.
- Consult with and refer cases to large MCO medical directors regularly, as necessary.
- Comply with required workplace safety standards.
Day to Day Responsibilities: - Manage all UM standard Inpatient, Outpatient, and Custodial Care processes and workflows for any requests.
- Provide verbal notifications for denials/partial denials to both members and providers.
- Participate in Interdisciplinary Team Meetings (IDTs).
- Manage personal queue and clinical reviews.
Must Have Skills: - Experience in Utilization Management (UM).
- Knowledge of Turnaround Timeframes and ability to manage them.
- Proficiency with computer systems and ability to learn new systems.
- Experience conducting clinical reviews and processing denials and partial denial determinations.
- Knowledge of MCG guidelines and ability to use them.
- Experience in case presentation for medical reviews.
- Familiarity with Medicaid/Medicare guidelines.
- Bi-lingual in Spanish, Bengali, or Mandarin preferred but not mandatory.
- Experience reviewing for Medicaid/MLTC members (not Medicare or IP reviews).
Required Years of Experience: - At least 1-2 years of experience in UM.
Required Licensure / Education: - NY State License as a Practical Nurse (LPN) or Registered Nurse (RN).
Additional Requirements: - Attendance is crucial. Candidates must not have any pre-planned vacations during October, November, or December due to a high volume of reassessments and increased authorization/requests during the holiday season.
- Any pre-planned vacations must be disclosed during the interview and submission process.
Knowledge/Skills/Abilities: - Excellent communication, problem-solving, and teamwork skills.
- Strong organizational skills with the ability to manage multiple priorities.
- Ability to work independently and handle multiple projects simultaneously.
- Knowledge of applicable state and federal regulations.
- In-depth knowledge of Interqual and other references for length of stay and medical necessity determinations.
- Experience with NCQA.
- Initiative and ability to see tasks to completion.
- Proficiency in Microsoft Office products.
- Strong verbal and written communication skills.
- Ability to abide by company policies and maintain confidentiality (HIPAA).
- Skilled at establishing and maintaining positive and effective work relationships with coworkers, clients, members, providers, and customers.
Required Education: - Completion of an accredited Registered Nursing program (a combination of experience and education will be considered in lieu of a Registered Nursing degree).
Required Licensure/Certification: - Active, unrestricted State Nursing (RN, LVN, LPN) license in good standing.
Job Tags
Remote job, Hourly pay, Holiday work,