[Hiring] Utilization Management Reviewer, RN @Excellus BCBS

Role Description

This position is responsible for coordinating, integrating, and monitoring the utilization of physical health (PH) medical and healthcare services for members, ensuring compliance with internal and external standards set by regulatory and accreditation entities. Refers appropriate cases to the Medical Director for review. Refer to and work closely with Case Management to address member needs. Participates in rotating on-call schedule, as required, to meet departmental time frames. Per department needs, may be responsible for additional hours.

Essential Accountabilities

• Performs pre-service, concurrent and post-service clinical reviews to determine the appropriateness of services requested for the diagnosis and treatment of members’ medical health conditions.
• Plans, implements, and documents utilization management activities incorporating clinical knowledge and members’ specific health plan benefits.
• Ensures compliance with corporate and departmental policy and procedure.
• Utilizes appropriate communication techniques with members and providers to obtain clinical information.
• Collaborates with hospital, home care, care management, and other providers to ensure clinical needs are met.
• Acts as a resource and liaison to the provider community.
• Makes accurate and consistent interpretation of required clinical criteria, medical policy, contract benefits, and State and Federal Mandates.
• May be responsible for pricing, coding, researching claims.
• Accountable for meeting departmental guidelines for timeliness, production, and metrics.
• Maintains compliance with all regulatory and accrediting standards.
• Assists with training and special projects, as assigned.
• Consistently demonstrates high standards of integrity.
• Maintains high regard for member privacy in accordance with corporate privacy policies.
• Regular and reliable attendance is expected and required.
• Performs other functions as assigned by management.

Level II (in addition to Level I Accountabilities)

• Offers process improvement suggestions and participates in solutions of more complex issues/activities.
• Mentors staff and assists with coaching, as necessary.
• Provides consistent positive results on audits.
• Works independently in coordinating and collaborating with members and providers.
• Manages more complex assignments; cross-trained to review various levels of care and/or services.
• Participates in committees and leads when required.

Level III (in addition to Level II Accountabilities)

• Displays leadership and serves as a positive role model to others in the department.
• Identifies, recommends, and assesses new processes to improve productivity.
• Assists in updating departmental policies and procedures.
• Serves as subject matter expert for escalations.
• Provides guidance and leadership to the daily activities of the Utilization Management Department clinical staff.
• Provides backup for the Supervisor, whenever necessary.
• Participates in the orientation of new staff and training opportunities.
• Assists Medical Director (MD) in projects as needed.

Qualifications

• Associates degree and active NYS RN license required; Bachelors degree preferred.
• Minimum of three years of clinical experience required; Utilization Management experience preferred.
• Must demonstrate proficiency with the Microsoft Office Suite.
• Demonstrates general understanding of coding standards.
• Maintains current and working knowledge of Utilization Management Standards.
• Experience in interpreting managed care benefit plans and strong knowledge of government program contracts preferred.
• Strong written and verbal communication skills.
• Ability to multitask and balance priorities.
• Must demonstrate ability to work independently on a daily basis.
• Deliver efficient, effective, and seamless care to members.

Requirements

• Level II: Minimum of 2 years in utilization management position.
• Demonstrates ability to escalate to management, as necessary.
• Demonstrates proficiency in all related technology.
• Ability to take on broader responsibilities.
• Ability to participate in training of new staff.

Benefits

• Compensation Range(s):
• Level I: Grade E2: Minimum: $62,400 - Maximum: $96,081
• Level II: Grade E3: Minimum: $62,400 - Maximum: $106,929
• Level III: Grade E4: Minimum: $65,346 - Maximum: $117,622
• Participation in group health and/or dental insurance.
• Retirement plan.
• Wellness program.
• Paid time away from work.
• Paid holidays.

Physical Requirements

• Ability to travel across the health plan service regions as needed.
• Ability to work at a computer for prolonged periods of time.