RN Utilization Management Specialist — Remote Opportunity

Excellus BCBS; United States; Hybrid; USD 62,000 - 117,000; Full time

Benefits offered by this job

Remote work option on case-by-case

Job summary

Excellus BCBS is seeking a Utilization Management professional to coordinate and monitor behavioral health and physical health services for members, ensuring compliance with internal and external standards. This role participates in on-call rotations and may require additional hours as department needs dictate.

The position supports clinical reviews, plans utilization management activities, and collaborates with providers to ensure timely access to care within benefits and policies.

Qualifications

• Associates degree and active NYS RN license required.
• Minimum of three (3) years of clinical experience required.
• Proficiency with the Microsoft Office Suite.
• Experience interpreting managed care benefit plans and government program contracts (Medicare/Medicaid) preferred.
• Strong written and verbal communication skills.
• Ability to multitask and balance priorities.
• Must demonstrate ability to work independently on a daily basis.

Responsibilities

• Performs pre-service, concurrent and post-service clinical reviews to determine appropriateness of services.
• Plans, implements, and documents utilization management activities.
• 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 with providers.
• Maintains compliance with regulatory and accrediting standards.
• Performs other functions as assigned by management.

Skills

Verbal communication

Written communication

Multitasking

Independent work

Education

Associates degree, NYS RN license

Bachelors degree preferred

Tools

Microsoft Office Suite

Job description

Excellus BCBS is seeking a Utilization Management professional to coordinate and monitor behavioral health and physical health services for members, ensuring compliance with internal and external standards. This role participates in on-call rotations and may require additional hours as department needs dictate.

The position supports clinical reviews, plans utilization management activities, and collaborates with providers to ensure timely access to care within benefits and policies.