Medicare Utilization Review RN – Impactful Care & Appeals

Hamaspik Choice; New York (NY); On-site; USD 56,000 - 65,000; Full time

Job summary

Hamaspik Choice is seeking a Medicare Utilization Management (UM) Nurse to review authorization requests for medical necessity and ensure appropriate utilization of healthcare services. This role oversees externals vendor reviews, works with multidisciplinary teams, and prepares Level II appeal summaries based on clinical criteria.

The position requires a valid New York State RN license, strong clinical judgment, and attention to detail, with duties including drafting compliant notices and

Qualifications

• Must have valid New York State RN license.
• Strong clinical judgment, analytical skills, and attention to detail are required.

Responsibilities

• Review and process authorization requests to determine medical necessity in line with Medicare criteria and policies.
• Oversee submissions and outcomes of clinical reviews performed by external vendor.
• Collaborate with multidisciplinary teams to promote timely access to medically necessary services.
• Prepare appeal summaries for Level II submissions with clinical rationale and records.
• Maintain Medicare Part C data and regulatory reports, ensuring data integrity.

Skills

Clinical judgment

Analytical skills

Attention to detail

Education

4 Year Degree

Job description

Hamaspik Choice is seeking a Medicare Utilization Management (UM) Nurse to review authorization requests for medical necessity and ensure appropriate utilization of healthcare services. This role oversees externals vendor reviews, works with multidisciplinary teams, and prepares Level II appeal summaries based on clinical criteria.

The position requires a valid New York State RN license, strong clinical judgment, and attention to detail, with duties including drafting compliant notices and