RN Utilization Management Reviewer — LTSS & Duals (Remote)

Excellus Health Plan Inc.; Buffalo (NY); Presencial; USD 62.000 - 118.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Remote work possible (case-by-case)

Descripción de la vacante

Excellus Health Plan Inc. in Buffalo, NY seeks an on-site Utilization Management RN to coordinate, integrate, and monitor clinical reviews for members, ensuring compliance with state and federal mandates.

You will work with case management, providers, and Medical Director, participating in on-call rotations and maintaining timely processing of reviews while advancing quality of care through collaboration and policy adherence.

Formación

• Associates degree and active NYS RN license required; Bachelor's preferred.
• Minimum of three years clinical experience; Utilization Management experience preferred.
• Proficient with Microsoft Office; understanding of coding standards and managed care benefits.

Responsabilidades

• Perform pre-service, concurrent, and post-service reviews to assess medical necessity.
• Plan and document utilization management activities aligned with policies and mandates.
• Collaborate with hospitals, home care, and providers to ensure no gaps in care.
• Act as liaison to providers and explain access processes to Health Plan.
• Maintain compliance with regulatory standards and participate in on-call rotation.

Conocimientos

Communication skills

Multitasking

Independent work

Educación

Associate degree; NYS RN license

Bachelor's degree preferred

Herramientas

Microsoft Office Suite

Descripción del empleo

Excellus Health Plan Inc. in Buffalo, NY seeks an on-site Utilization Management RN to coordinate, integrate, and monitor clinical reviews for members, ensuring compliance with state and federal mandates.

You will work with case management, providers, and Medical Director, participating in on-call rotations and maintaining timely processing of reviews while advancing quality of care through collaboration and policy adherence.