RN Utilization Management Reviewer – LTSS & Duals (Hybrid/Remote)

Excellus BCBS; Town of De Witt (NY); Hybrid; USD 62,000 - 118,000; Full time

Job summary

Excellus BCBS in New York seeks a Utilization Management Nurse to coordinate and monitor physical health services for members, ensuring compliance with standards. You will perform pre/service, concurrent, and post/service reviews, collaborate with providers and case management, and relay information to physicians as needed.

Qualifications include an Associate degree and NYS RN license, 3+ years clinical UM experience, proficiency with Microsoft Office, and knowledge of coding standards and

Qualifications

• Associates degree and active NYS RN license required.
• Minimum of three years of clinical experience required.
• Demonstrates proficiency with the Microsoft Office Suite.
• Demonstrates general understanding of coding standards.
• Maintains current knowledge of Utilization Management Standards.
• Experience interpreting managed care contracts (Medicare/Medicaid) preferred.
• Strong written and verbal communication skills.
• Ability to multitask and work independently.

Responsibilities

• Perform pre-service, concurrent and post-service clinical reviews to determine appropriateness of services.
• Plan, implement and document utilization management activities; refer issues to Medical Director.
• Communicate with members and providers to gather clinical information and assess 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 to providers and obtain case management support.

Skills

RN license

Microsoft Office

Communication

Independent work

Education

Associate degree

NYS RN license

Bachelor's degree preferred

Tools

Microsoft Office Suite

Job description

Excellus BCBS in New York seeks a Utilization Management Nurse to coordinate and monitor physical health services for members, ensuring compliance with standards. You will perform pre/service, concurrent, and post/service reviews, collaborate with providers and case management, and relay information to physicians as needed.

Qualifications include an Associate degree and NYS RN license, 3+ years clinical UM experience, proficiency with Microsoft Office, and knowledge of coding standards and