RN Utilization Management Reviewer - LTSS & Duals (Remote)

Excellus BCBS; Buffalo (NY); Presencial; USD 62.000 - 118.000; Jornada completa

Descripción de la vacante

Excellus BCBS in New York is seeking a Utilization Management professional to coordinate the use of physical health services for members, applying clinical criteria and policies to determine care appropriateness.

You will collaborate with Case Management, providers, and hospital teams, participate in on-call coverage, and ensure adherence to regulatory standards while supporting efficient care delivery.

Formación

• Associates degree and active NYS RN license required. Bachelors degree preferred.
• Minimum of three years of clinical experience required. Utilization Management experience preferred.
• Must demonstrate proficiency with the Microsoft Office Suite
• Demonstrates general understanding of coding standards
• Maintains current and working knowledge of Utilization Management Standards.
• Experience in interpreting managed care benefit plans and strong knowledge of government program contracts (Medicare and Medicaid) and benefits, preferred.
• Strong written and verbal communication skills
• Ability to multitask and balance priorities.
• Must demonstrate ability to work independently on a daily basis.
• Deliver efficient, effective, and seamless care to members.

Responsabilidades

• Coordinate, integrate, and monitor the utilization of physical health (PH) medical and healthcare services for members.
• Refer to and work closely with Case Management to address member needs.
• Participates in rotating on-call schedule, as required, to meet departmental time frames.
• May be responsible for additional hours.
• Collaborates with hospital, home care, care management, and other providers to ensure that clinical needs are met.
• Maintains compliance with regulatory and accrediting standards.
• Provides guidance and acts as a resource within Utilization Management.

Conocimientos

RN license

Microsoft Office

Communication skills

Multitasking

Independent work

Educación

Associates degree & NYS RN license

Bachelor's degree preferred

Herramientas

Microsoft Office Suite

Descripción del empleo

Excellus BCBS in New York is seeking a Utilization Management professional to coordinate the use of physical health services for members, applying clinical criteria and policies to determine care appropriateness.

You will collaborate with Case Management, providers, and hospital teams, participate in on-call coverage, and ensure adherence to regulatory standards while supporting efficient care delivery.