RN - Utilization Review

Salary: $68,640 - $93,600 Overview:

• Monday-Friday Schedule w/ no weekends or overnights
• Hybrid working options
• Medical, Dental & Vision upon 1st of month following 60 days of hire
• Up to 140 hours (19 days) of PTO time PLUS six (6) holidays within the 1st year
• 401(k) retirement plan with vested employer match up to 4%
• Substantial Referral program

Responsibilities:

• Conduct internal utilization audits and risk analysis.
• Review on-going authorizations to ensure they match the members risk score and chronic conditions.
• Supports quality assurance and performance improvement activities including, but not limited to, analyzing clinical data to identify trends and opportunities, recommending improvements, and serving as a subject matter expert for the organization.
• Modify/create authorizations for enrolled members
• Reviews requests for medical necessity
• Manage the Grievance and Appeals process and address Fair Hearings when necessary.
• Conduct outreaches to fill gaps in care for Quality Indicators
• Obtain state ordered documentation to ensure members can receive services (4359, 3559)
• Assist members in accessing services, including making appointments for members when appropriate and providing patient teaching and support to facility compliance with treatment.
• Reviews SNF members of which have been deemed permanently placed and conducts outreaches to ensure they are batch disenrolled etc.
• Develops processes, policies, and workflows necessary to meet enrollments, and business goals.
• Monitor and coordinate follow up meetings for Critical Events, Falls, etc.
• Participate and conduct a claims review between Care Management and Finance.
• Monitor and review on-going tracking systems to ensure services are in place.
• Review member medical records and ensure duplication of services is not occurring.
• Review and implement NYS/DOH policies and procedures as needed.
• Manage and review member complaints.
• Fill out appropriate checklists and outreaches to providers for DME/Authorization requests.
• Works with the quality review team to ensure the accuracy and completeness of all necessary documentation

Qualifications:

• Must have a valid and active Registered Nurse licensure in New York State.
• 3-5 years of Utilization Management experience, Required.
• Self-directed planning, problem solving, and analytical thinking.
• Knowledge of ICD-10 and CPT methodology.
• Knowledge of NYS risk score and VBP methodology
• Knowledge of Microsoft Office

• Must be in good standing with the Medicare and Medicaid programs.
• Must possess exemplary computer skills, including mastery of data processing systems, Microsoft Office Suite, e-mail systems, electronic medical records, and web-based programs.
• HIPAA Privacy

• This position requires regular interaction with residents, coworkers, visitors, and/or supervisors. In order to ensure a safe work environment for residents, coworkers, visitors, and/or supervisors of the Company, and to permit unfettered communication between the employee and those residents, coworkers, visitors, and supervisors, this position requires that the employee be able to read, write, speak, and understand the English language at an intermediate or more advanced level.

EOE Statement: WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.