RN Utilization Management Specialist - LTSS & Duals

Capital District Physicians Health Plan Inc; City of Binghamton (NY); On-site; USD 62,000 - 118,000; Full time

Job summary

Capital District Physicians Health Plan Inc. seeks a Utilization Management professional to coordinate clinical reviews and ensure appropriate services for members.

The role collaborates with hospital, home care, and care management teams to close gaps in care and ensure compliant utilization management. The position requires NYS RN license, an associate degree, and three years of clinical UM experience, with strong communication skills and MS Office proficiency.

Qualifications

• Associates degree and active NYS RN license required. Bachelors degree preferred.
• Minimum of three years of clinical experience required. Utilization Management experience preferred.
• Proficiency with Microsoft Office Suite.
• Understanding of coding standards.
• Current knowledge of Utilization Management Standards.
• Experience interpreting managed care benefit plans and government program contracts (Medicare and Medicaid) preferred.
• Strong written and verbal communication skills.
• Ability to multitask and balance priorities.
• Ability to work independently and deliver efficient care.

Responsibilities

• Perform pre-service, concurrent and post-service clinical reviews to determine appropriateness of services for diagnosis and treatment of members' medical health conditions, applying established clinical review criteria and contractual benefits.
• Plan, implement and document utilization management activities with understanding of clinical knowledge and member benefits; refer issues to Medical Director.
• Obtain clinical information from members and providers; assess medical necessity and advocate for needed services.
• Collaborate with hospital, home care, care management and other providers to ensure needs are met and no gaps in care.
• Explain processes to providers for accessing Health Plan to perform medical review; obtain case or disease management support.
• Interpret clinical criteria, medical policy, contract benefits, and state/federal mandates accurately.
• May price, code, and research claims to ensure correct application of benefits.
• Meet departmental timeliness, production and audit requirements.
• Maintain compliance with regulatory and accrediting standards and stay updated on changes.
• Assist with training and special projects.
• Maintain member privacy in accordance with corporate policies.
• Maintain regular attendance and perform other functions as assigned.

Skills

Clinical experience

Utilization Management experience

Microsoft Office Suite

Coding standards understanding

UM Standards

Managed care benefits knowledge

Communication skills

Multitasking

Independent work capability

Education

Associate degree

NYS RN license

Bachelor's degree

Job description

Capital District Physicians Health Plan Inc. seeks a Utilization Management professional to coordinate clinical reviews and ensure appropriate services for members.

The role collaborates with hospital, home care, and care management teams to close gaps in care and ensure compliant utilization management. The position requires NYS RN license, an associate degree, and three years of clinical UM experience, with strong communication skills and MS Office proficiency.