[Hiring] Utilization Management Reviewer, RN @company

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, applying established clinical review criteria, guidelines and medical policies and contractual benefits as well as State and Federal Mandates.
• Plans, implements, and documents utilization management activities which incorporate a thorough understanding of clinical knowledge, members’ specific health plan benefits, and efficient care delivery processes.
• Ensures compliance with corporate and departmental policy and procedure, identifies and refers potential quality of care and utilization issues to Medical Director.
• Utilizes appropriate communication techniques with members and providers to obtain clinical information, assesses medical necessity of services, advocating for members in obtaining needed services.
• Collaborates with hospital, home care, care management, and other providers effectively to ensure that clinical needs are met and that there are no gaps in care.
• Acts as a resource and liaison to the provider community in conjunction with Provider Relations.
• 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 to ensure accurate application of contract benefits and Corporate Medical Policies.
• Accountable for meeting departmental guidelines for timeliness, production and metrics and meeting requirements established for audits.
• Maintains compliance with all regulatory and accrediting standards.
• Assists with training and special projects, as assigned.
• Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies’ mission and values.
• Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.
• 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 the 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.
• Participate in committees and lead 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 and gain efficiencies.
• Assists in updating departmental policies, procedures, and desk level procedures.
• Expert and resource for escalations.
• Mentor to others in department.
• Provides backup for the Supervisor, whenever necessary.
• Participates in the orientation of new staff and training opportunities for all staff.
• 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 (Medicare and Medicaid) 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
• Other components of the total rewards package may include participation in group health and/or dental insurance, retirement plan, wellness program, paid time away from work, and paid holidays.
• Opportunity for remote work within all jobs posted by the Excellus Talent Acquisition team.

Company Description

Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.