Remote RN Utilization Reviewer - Care & Outcomes

Capital District Physicians Health Plan Inc; City of Utica (NY); Hybrid; USD 62.000 - 118.000; Vollzeit

Zusammenfassung

Capital District Physicians Health Plan Inc. seeks an experienced Utilization Management professional to coordinate and monitor medical services for members in New York.

You will perform clinical reviews, document management activities, and collaborate with providers to ensure timely, appropriate care while maintaining regulatory compliance. The role involves on-call rotation, cross-functional coordination, and potential for additional hours per department needs.

Qualifikationen

• Associates degree and active NYS RN license required; Bachelor's degree preferred.
• Minimum of three years of clinical experience; Utilization Management experience preferred.
• Proficient with Microsoft Office Suite.
• Understanding of coding standards.
• Knowledge of government program contracts (Medicare/Medicaid) preferred.
• Strong written and verbal communication; ability to multitask.
• Ability to work independently; deliver efficient, seamless care.

Aufgaben

• Pre-service, concurrent and post-service clinical reviews to determine appropriateness of services.
• Plan and document utilization management activities meeting policy and regulatory mandates.
• Communicate with members and providers to obtain clinical information and assess medical necessity.
• Collaborate with hospital, home care, care management to ensure no gaps in care.
• Explain processes for accessing Health Plan and obtain case or disease management support.
• Maintain compliance with regulatory standards and privacy policies.
• Participate in rotating on-call schedule.
• Assist with training and special projects.

Kenntnisse

Utilization management experience

Strong written and verbalcommunication

Multitasking

Independent work

Travel ability

Ausbildung

Associates degree

NYS RN license

Bachelor's degree preferred

Tools

Microsoft Office Suite

Jobbeschreibung

Capital District Physicians Health Plan Inc. seeks an experienced Utilization Management professional to coordinate and monitor medical services for members in New York.

You will perform clinical reviews, document management activities, and collaborate with providers to ensure timely, appropriate care while maintaining regulatory compliance. The role involves on-call rotation, cross-functional coordination, and potential for additional hours per department needs.