RN Utilization Mgmt Reviewer - Care Coordination Expert

Univera Healthcare; Buffalo (NY); Remote; USD 62,000 - 118,000; Full time

Job summary

Univera Healthcare in Buffalo, NY seeks a utilization management professional to coordinate, integrate and monitor health services for members, ensuring compliance with policies and regulatory standards. You will work with medical directors, case management, and providers to meet member needs and maintain high-quality care.

The role includes on-call participation and potential additional hours as required, with escalating responsibilities across Level I–III as you grow in the role.

Qualifications

• Associates degree and NYS RN license required.
• Minimum of three years of clinical experience; Utilization Management experience preferred.
• Proficient with 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

• Performs pre-service, concurrent and post-service clinical reviews to determine appropriateness of services.
• Plans, implements, and documents utilization management activities.
• Assesses medical necessity of services and advocates for members.
• Collaborates with hospital, home care and providers to ensure no gaps in care.
• Acts as a liaison to providers and explains Health Plan processes for access to services.
• Maintains compliance with regulatory and corporate policies.
• Participates in training and special projects as assigned.
• Maintains member privacy and professionalism at all times.

Skills

Communication skills

Multitasking

Microsoft Office

Coding standards understanding

Utilization Management experience

Education

Associates degree

NYS RN license

Bachelors degree preferred

Tools

Microsoft Office Suite

Job description

Univera Healthcare in Buffalo, NY seeks a utilization management professional to coordinate, integrate and monitor health services for members, ensuring compliance with policies and regulatory standards. You will work with medical directors, case management, and providers to meet member needs and maintain high-quality care.

The role includes on-call participation and potential additional hours as required, with escalating responsibilities across Level I–III as you grow in the role.