RN Utilization Management Reviewer: LTSS & Duals (Remote-Eligible)

Excellus BCBS; City of Utica (NY); Hybrid; USD 62,000 - 96,000; Full time

Job summary

Excellus BCBS in New York is seeking a Health Utilization Management professional to coordinate, integrate, and monitor the utilization of physical health services for members. The role requires collaboration with Case Management, referral to Medical Director, and participation in rotating on-call shifts.

The position involves applying clinical review criteria, ensuring compliance with regulatory standards, and supporting access to necessary care while maintaining member privacy and high-quality

Qualifications

• Associates degree and active NYS RN license required.
• Minimum of three years of clinical experience required.
• Utilization Management experience preferred.
• Proficient with Microsoft Office Suite.
• Strong knowledge of government program contracts (Medicare/Medicaid) preferred.

Responsibilities

• Performs pre-service, concurrent and post-service clinical reviews to determine appropriateness of services.
• Plans, implements, and documents utilization management activities.
• Uses appropriate communication techniques with members and providers to obtain clinical information and assess medical necessity.
• Collaborates with hospital, home care, care management and other providers to ensure no gaps in care.
• Explains processes for accessing Health Plan to perform medical review and obtain case management support.

Education

Associates degree

Active NYS RN license

Bachelor's degree preferred

Job description

Excellus BCBS in New York is seeking a Health Utilization Management professional to coordinate, integrate, and monitor the utilization of physical health services for members. The role requires collaboration with Case Management, referral to Medical Director, and participation in rotating on-call shifts.

The position involves applying clinical review criteria, ensuring compliance with regulatory standards, and supporting access to necessary care while maintaining member privacy and high-quality