RN Utilization Management Reviewer—SN LTSS & Duals (Remote)

Capital District Physicians’ Health Plan, Inc.; Buffalo (NY); Presencial; USD 62.000 - 118.000; Jornada completa

Descripción de la vacante

Capital District Physicians’ Health Plan, Inc. seeks a Utilization Management professional to coordinate reviews and collaborate with members, providers, and the Medical Director. The role requires an active NYS RN license, an associates degree, and UM experience to ensure compliant, efficient care.

You will participate in on-call rotations, mentor staff, and support process improvements across levels I–III. A strong knowledge of managed care contracts and coding standards is valuable.

Formación

• Associates degree and NYS RN license required; Bachelor's degree preferred.
• Minimum of three years of clinical experience; Utilization Management experience preferred.
• Proficiency with the Microsoft Office Suite.
• Demonstrates understanding of coding standards.
• Knowledge of Utilization Management Standards.
• Experience interpreting managed care benefit plans; Medicare/Medicaid knowledge preferred.
• Strong written and verbal communication skills.
• Ability to multitask and balance priorities.
• Ability to work independently daily.
• Deliver efficient, seamless care to members.

Responsabilidades

• Coordinate pre-service, concurrent and post-service reviews to determine medical necessity.
• Collaborate with providers and health plans to meet member needs and ensure continuity of care.
• Assist in training and special projects within the UM department.
• Mentor staff and participate in committees as needed.
• Lead process improvements and handle escalated issues in UM.

Conocimientos

Communication skills

Multitasking

Independent work

Microsoft Office

Medical coding awareness

Regulatory knowledge

Member advocacy

Team collaboration

Educación

NYS RN license

Associates degree

Bachelor's degree preferred

Herramientas

Microsoft Office Suite

Descripción del empleo

Capital District Physicians’ Health Plan, Inc. seeks a Utilization Management professional to coordinate reviews and collaborate with members, providers, and the Medical Director. The role requires an active NYS RN license, an associates degree, and UM experience to ensure compliant, efficient care.

You will participate in on-call rotations, mentor staff, and support process improvements across levels I–III. A strong knowledge of managed care contracts and coding standards is valuable.