Nurse Case Manager - Utilization

1199seiubenefits; New York (NY); On-site; USD 95,000 - 125,000; Full time

Job summary

A healthcare organization in New York is seeking a Registered Nurse for Utilization Management. The role involves assessing, planning, and coordinating service delivery through case management. Candidates must hold a Bachelor's degree and a valid NY RN license, along with a minimum of three years of Medical/Surgical and two years of Utilization Management experience. Strong problem-solving and communication skills are essential, with a focus on maintaining compliance and quality outcomes.

Qualifications

• Bachelor’s degree and Valid New York State Registered Nurse (RN) required.
• Minimum three years Medical/Surgical experience plus two years Utilization Management experience required.
• Proficient in Utilization Management criteria and Medicare guidelines.

Responsibilities

• Assess, plan and provide ongoing coordination through case management.
• Perform medical necessity reviews to ensure compliance.
• Maintain accurate records of patient interactions.
• Maintain accurate records in designated medical management system.
• Provide recommendations and discuss cases with Medical Consultants.
• Meet timelines and quality standards for Utilization Management.
• Submit reports/logs on reviewed activities per UM procedures.
• Participate in quality improvement activities within programs.
• Authorize vendor services using established criteria for care decisions.
• Ensure compliance with state mandated regulations.
• Identify and solve issues to ensure cost-efficient services.
• Support care management programs to ensure quality operations.

Skills

Clinical assessment

Care planning skills

Problem-solving

Verbal and written communication

Utilization Management criteria application

Microsoft Office skills

Medical coding

Education

Bachelor’s degree

Valid New York State Registered Nurse (RN) license

New York State Registered Nurse license

Certification in Case Management (CCM)

Tools

Milliman Care Guidelines

Health claims processing systems

Medical coding systems

Job description

Responsibilities

• Use industry criteria, benefit plan design, clinical knowledge, and critical thinking to assess, plan and provide, ongoing coordination and management of service delivery through an integrated case management approach
• Performs medical necessity review that includes concurrent, prospective, retrospective reviews and 1st level appeals, to ensure compliance with applicable criteria, medical policy, member eligibility, benefits and vendor contracts.
• Apply Milliman Care Guidelines, internal Policies and Reference Guides to determine appropriateness of services/equipment that require Prior Authorization
• Maintain accurate records of all patient/provider/vendor related interactions in designated medical management system
• Apply clinical guidelines, provide recommendations and discuss cases with Medical Consultants
• Meet timelines and quality standards related to Utilization Management
• Maintain and submit reports and logs on reviewed activities as outlined by the UM program operational procedures
• Identify and participate in quality improvement activities as it relates to internal programs, processes studies and projects
• Authorize vendor services using clinically proven criteria to make consistent care decisions
• Maintain compliance with all state mandated regulations
• Identify and problem solve issues with appropriate services to ensure positive member outcomes utilizing cost efficient covered services
• Responsible for abiding by and supporting the care management programs in order to ensure quality and efficient clinical operations
• Perform additional duties and projects as assigned by management

Qualifications

• Bachelor’s degree; Valid New York State Registered Nurse (RN) required
• Minimum three (3) years Medical/Surgical experience plus a minimum of two (2) years Utilization Management experience required
• BSN and Certification in Case Management a plus
• Proficient in application and use of industry standard Utilization Management criteria (Milliman Care Guidelines), Medicare and coverage guidelines, health claims processing, medical coding
• Excellent verbal and written communication skills, problem-solving, clinical assessment, care planning skills, and independent decision-making capability
• Computer and organizational skills required, ability to manage competing priorities, multi-task with results-oriented outcomes and work in a fast paced environment. Intermediate skills of Microsoft Office systems preferred.