RN Utilization Management Specialist — Care Coordination

Excellus BCBS; City of Binghamton (NY); On-site; USD 62,000 - 118,000; Full time

Benefits offered by this job

Health insurance

Retirement plan

Wellness program

Paid time off

Paid holidays

Job summary

Excellus BCBS in New York state seeks a Utilization Management professional to coordinate, integrate, and monitor the utilization of behavioral health or physical health services for members. You will refer cases for Medical Director review and work closely with Case Management to address member needs.

The role requires a NYS RN license, an associate degree, and a minimum of three years of clinical experience, with strong MS Office skills and the ability to multitask in a fast-paced environment.

Qualifications

• Associates degree and NYS RN license required.
• Minimum of three (3) years of clinical experience; UM experience preferred.
• Proficient in Microsoft Office Suite.
• Understanding of coding standards.
• Knowledge of government program 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 for BH/PH cases.
• Plan, implement and document utilization management activities.
• Collaborate with hospital, home care, care management and providers to ensure no gaps in care.
• Explain processes to providers and obtain case or disease management support.
• Maintain compliance with regulatory standards and corporate policies.

Skills

RN license

Clinical experience

Microsoft Office

Communication skills

Education

Associates degree

NYS RN license

Job description

Excellus BCBS in New York state seeks a Utilization Management professional to coordinate, integrate, and monitor the utilization of behavioral health or physical health services for members. You will refer cases for Medical Director review and work closely with Case Management to address member needs.

The role requires a NYS RN license, an associate degree, and a minimum of three years of clinical experience, with strong MS Office skills and the ability to multitask in a fast-paced environment.