Senior Utilization Review Nurse - CMS Compliance Leader

Hamaspik Choice; Village of Spring Valley (NY); Presencial; USD 110.000 - 120.000; Jornada completa

Descripción de la vacante

Hamaspik Choice in Spring Valley, NY seeks a licensed Utilization Review Nurse to lead Medicare review activities, oversee DRG validation, and ensure decisions align with CMS guidelines. You will coordinate with external review entities and internal teams to optimize the utilization workflow.

The role requires a 4-year degree, strong regulatory knowledge, and collaboration with clinical staff and vendors to maintain compliant, evidence-based reviews.

Formación

• 4 Year Degree required.

Responsabilidades

• Oversee daily operational workflows of the Medicare Utilization Review team.
• Review retrospective DRG assignments and level-of-care decisions for medical necessity and accuracy.
• Monitor inpatient utilization and admissions for CMS-aligned medical necessity and appropriateness of care.
• Coordinate reviews with Physician Review Organizations and vendor partners to implement best practices in DRG validation and claims review.
• Prepare clinical summaries for Medicare appeals and ensure documentation supports IRE submissions.
• Provide daily clinical guidance to UM staff and respond to regulatory questions related to utilization management.
• Conduct audits of outcomes and denial language to ensure patient-friendly communication and regulatory compliance.

Educación

4 Year Degree

Descripción del empleo

Hamaspik Choice in Spring Valley, NY seeks a licensed Utilization Review Nurse to lead Medicare review activities, oversee DRG validation, and ensure decisions align with CMS guidelines. You will coordinate with external review entities and internal teams to optimize the utilization workflow.

The role requires a 4-year degree, strong regulatory knowledge, and collaboration with clinical staff and vendors to maintain compliant, evidence-based reviews.