RN Utilization Management Reviewer – LTSS & Duals

Excellus BCBS; City of Binghamton (NY); On-site; USD 62,000 - 96,000; Full time

Benefits offered by this job

Health and dental insurance

Retirement plan

Wellness program

Paid time off

Paid holidays

Job summary

Excellus BCBS is seeking a Utilization Management RN to coordinate clinical reviews of physical health services for members, ensuring alignment with medical policies and regulatory standards. You will work with Medical Directors and Case Management to address member needs and ensure timely care.

Responsibilities include on-call participation, collaboration across hospital and home care teams, and adherence to quality metrics.

Qualifications

• Associates degree and active NYS RN license required.
• Minimum of three years of clinical experience required.
• Proficiency with the Microsoft Office Suite.

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 no gaps in care.
• Maintains compliance with regulatory and accrediting standards.

Skills

Communication skills

Multitasking

Independent work

Education

Nursing degree + NYS RN license

Bachelor’s degree preferred

Tools

Microsoft Office

Job description

Excellus BCBS is seeking a Utilization Management RN to coordinate clinical reviews of physical health services for members, ensuring alignment with medical policies and regulatory standards. You will work with Medical Directors and Case Management to address member needs and ensure timely care.

Responsibilities include on-call participation, collaboration across hospital and home care teams, and adherence to quality metrics.