RN Utilization Management Reviewer: LTSS & Duals

Capital District Physicians Health Plan Inc; City of Albany (NY); Remote; USD 62,000 - 107,000; Full time

Job summary

Capital District Physicians Health Plan Inc is seeking a Utilization Management professional to coordinate, integrate, and monitor health services for members. The role supports case management, collaborates with providers, and ensures compliance with state and federal mandates.

The position involves on-call rotation and may include additional hours to meet departmental needs. Strong communication and multitasking skills are essential for delivering efficient member care.

Qualifications

• Associates degree and NYS RN license required; Bachelors degree preferred.
• Minimum of three years of clinical experience required; Utilization Management experience preferred.
• Proficiency with the Microsoft Office Suite.
• Demonstrates general understanding of coding standards.
• Maintains current and working knowledge of Utilization Management Standards.
• Experience interpreting managed care benefit plans; Medicare/Medicaid knowledge preferred.

Responsibilities

• Performs pre-service, concurrent and post-service clinical reviews to determine the appropriateness of services.
• Plans, implements and documents utilization management activities.
• Collaborates with hospital, home care, care management and other providers to ensure care gaps are closed.
• Acts as liaison to provider community with Health Plan processes for medical review.
• Interprets clinical criteria, medical policy, and contract benefits accurately.
• Maintains compliance with regulatory and accreditation standards.

Skills

Strong written and verbalcommunication

Multitasking ability

Independent work

Delivery of efficient care

Education

Associates degree and active NYS RN license

Bachelors degree preferred

Tools

Microsoft Office Suite

Job description

Capital District Physicians Health Plan Inc is seeking a Utilization Management professional to coordinate, integrate, and monitor health services for members. The role supports case management, collaborates with providers, and ensures compliance with state and federal mandates.

The position involves on-call rotation and may include additional hours to meet departmental needs. Strong communication and multitasking skills are essential for delivering efficient member care.