RN Utilization Management Reviewer for Care Coordination

Excellus BCBS; United States; Remoto; USD 62.000 - 118.000; Tempo pieno

Descrizione del lavoro

Excellus BCBS in the United States is seeking a Utilization Management RN to coordinate, review, and monitor medical services for members, ensuring compliance with clinical policies and regulatory standards. The role involves working with members and providers to obtain clinical information, assess medical necessity, and support efficient care delivery across care settings.

The position requires an Associate degree, NYS RN license, and at least 3 years of UM experience, with travel as needed.

Competenze

• Associates degree and NYS RN license required; Bachelor's degree preferred.
• Minimum of three years of clinical experience; Utilization Management experience preferred.
• Proficiency with the Microsoft Office Suite.
• Demonstrates understanding of coding standards.
• Experience interpreting managed care benefit plans; Medicare/Medicaid knowledge preferred.
• Strong written and verbal communication skills.
• Ability to multitask and work independently.
• Deliver efficient, effective, and seamless care to members.

Mansioni

• Performs pre-service, concurrent and post-service clinical reviews to determine appropriateness of services.
• Plans, implements, and documents utilization management activities.
• Communicates with members and providers to obtain clinical information and assess medical necessity.
• Collaborates with hospital, home care, care management and other providers to meet clinical needs.
• Explains processes for accessing health plan to perform medical review and obtain case management support.
• Maintains compliance with regulatory and departmental policy/procedures.
• Participates in on-call schedule and supports additional hours as needed.
• Mentors staff and supports training for new staff.

Conoscenze

Communication skills

Multitasking

Microsoft Office

Coding standards

Utilization Management

Formazione

NYS RN license

Associates degree

Bachelor's degree preferred

Strumenti

Microsoft Office Suite

Descrizione del lavoro

Excellus BCBS in the United States is seeking a Utilization Management RN to coordinate, review, and monitor medical services for members, ensuring compliance with clinical policies and regulatory standards. The role involves working with members and providers to obtain clinical information, assess medical necessity, and support efficient care delivery across care settings.

The position requires an Associate degree, NYS RN license, and at least 3 years of UM experience, with travel as needed.