Senior RN - Utilization Management (SN LTSS & Duals)

Excellus BCBS; Oregon; Hybrid; USD 62,000 - 118,000; Full time

Benefits offered by this job

Remote work opportunities

Job summary

Excellus BCBS is seeking a Utilization Management professional to coordinate and monitor healthcare services for members. The role requires clinical review across pre-service, concurrent, and post-service stages, ensuring alignment with policies and state/federal mandates.

You will work with providers to obtain information, advocate for appropriate access to services, and participate in on-call rotations as needed. A NYS RN license and UM experience are preferred.

Qualifications

• Associates degree and active NYS RN license required. Bachelors degree preferred.
• Minimum of three years of clinical experience. Utilization Management experience preferred.
• Proficiency with the Microsoft Office Suite and an understanding of coding standards.

Responsibilities

• Perform pre-service, concurrent and post-service clinical reviews to determine appropriateness of services.
• Plan, implement and document utilization management activities and ensure regulatory compliance.
• Communicate with members and providers to obtain clinical information and assess medical necessity.

Skills

Communication skills

Multitasking

Independent work

Education

Associate's degree

NYS RN license

Bachelor's degree preferred

Tools

Microsoft Office Suite

Coding standards knowledge

Job description

Excellus BCBS is seeking a Utilization Management professional to coordinate and monitor healthcare services for members. The role requires clinical review across pre-service, concurrent, and post-service stages, ensuring alignment with policies and state/federal mandates.

You will work with providers to obtain information, advocate for appropriate access to services, and participate in on-call rotations as needed. A NYS RN license and UM experience are preferred.