RN Utilization Management Reviewer - LTSS & Duals

Capital District Physicians Health Plan Inc; Buffalo (NY); Presencial; USD 62.000 - 118.000; Jornada completa

Descripción de la vacante

Capital District Physicians' Health Plan Inc is seeking an experienced Utilization Management professional to coordinate and monitor health services for members. You will review services for medical necessity, collaborate with providers, and support case management to ensure seamless care delivery.

Role involves on-site coordination with hospitals and care teams, participating in audits, and contributing to process improvements across levels I–III.

Formación

• 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.
• Understanding of coding standards; knowledge of government program contracts is a plus.
• Strong written and verbal communication; ability to multitask and work independently.

Responsabilidades

• Perform pre-service, concurrent and post-service clinical reviews to determine appropriateness of services.
• Plan, implement and document utilization management activities.
• Communicate with members and providers to obtain clinical information and determine medical necessity.
• Collaborate with hospital, home care, care management and other providers to ensure no gaps in care.
• Explain processes for accessing Health Plan services and obtaining case/disease management support.
• Assist with audits, training and departmental projects.

Conocimientos

Written communication

Verbal communication

Multitasking

Independent work

Microsoft Office

Coding standards

Utilization Management

Regulatory knowledge

Educación

Associates degree + NYS RN license

Bachelor’s degree preferred

Herramientas

Microsoft Office Suite

Descripción del empleo

Capital District Physicians' Health Plan Inc is seeking an experienced Utilization Management professional to coordinate and monitor health services for members. You will review services for medical necessity, collaborate with providers, and support case management to ensure seamless care delivery.

Role involves on-site coordination with hospitals and care teams, participating in audits, and contributing to process improvements across levels I–III.