RN Utilization Review Specialist

Excellus BCBS; Town of De Witt (NY); On-site; USD 80,000 - 110,000; Full time

Job summary

Excellus BCBS in New York seeks a Utilization Management professional to coordinate behavioral and physical health services for members. You will perform clinical reviews, ensure medical necessity, and collaborate with hospital and care-management teams to close gaps in care.

Strong attention to policy and privacy is required. Requirements include an associates degree with NYS RN license and at least three years of UM experience, plus proficiency with Microsoft Office.

Qualifications

• Associates degree and NYS RN license required; a Bachelor's degree is preferred.
• Minimum of three years of clinical experience; utilization management experience preferred.
• Proficiency with Microsoft Office; basic coding standards knowledge.
• Strong written and verbal communication; ability to multitask.

Responsibilities

• Perform pre-service, concurrent and post-service clinical reviews for BH/PH services.
• Plan and document utilization management activities ensuring compliance with policies.
• Assess medical necessity and advocate for members to obtain needed services.
• Collaborate with hospital, home care, and care management to avoid gaps in care.
• Explain processes to providers and assist with case management support.
• Maintain privacy and compliance with regulatory standards.

Skills

Utilization Management

Communication skills

Multitasking

Independent work

Education

Associates degree and NYS RN license

Bachelors degree preferred

Tools

Microsoft Office

Job description

Excellus BCBS in New York seeks a Utilization Management professional to coordinate behavioral and physical health services for members. You will perform clinical reviews, ensure medical necessity, and collaborate with hospital and care-management teams to close gaps in care.

Strong attention to policy and privacy is required. Requirements include an associates degree with NYS RN license and at least three years of UM experience, plus proficiency with Microsoft Office.