Utilization Management Reviewer, RN (Commercial)

Univera Healthcare; Buffalo (NY); Remote; USD 60,000 - 118,000; Full time

Job summary

A leading company in healthcare is seeking a Utilization Management Reviewer, RN to coordinate and monitor healthcare services for members while ensuring compliance with regulations. The role involves clinical reviews, effective communication with members and providers, and collaboration to prevent care gaps. The ideal candidate will have an RN license and clinical experience, with a competitive salary ranging from $60,410 to $117,622 based on qualifications.

Qualifications

• Associates degree and active NYS RN license required; Bachelors preferred.
• At least three years of clinical experience, with utilization management experience preferred.
• Proficient in Microsoft Office.

Responsibilities

• Performs clinical reviews to determine the appropriateness of medical services.
• Plans and documents utilization management activities, ensuring compliance.
• Collaborates with hospitals and providers to meet clinical needs.

Skills

Clinical experience

Communication skills

Knowledge of managed care benefit plans

Education

Associates degree in nursing

Active NYS RN license

Bachelors in nursing (preferred)

Tools

Microsoft Office

Job description

Join to apply for the Utilization Management Reviewer, RN (Commercial) role at Univera Healthcare.

This position is responsible for coordinating, integrating, and monitoring the utilization of physical health (PH) medical and healthcare services for members, ensuring compliance with internal and external standards set by regulatory and accreditation entities. Refers appropriate cases to the Medical Director for review. Refer to and work closely with Case Management to address member needs.

Participates in rotating on-call schedule, as required, to meet departmental time frames. May be responsible for additional hours based on department needs.

Essential Responsibilities/Accountabilities

Level I:

• Performs pre-service, concurrent and post-service clinical reviews to determine the appropriateness of services requested for members’ medical health conditions, applying established clinical review criteria, guidelines, and medical policies as well as State and Federal Mandates.
• Plans, implements, and documents utilization management activities, ensuring compliance with policies and identifying potential quality of care issues.
• Communicates effectively with members and providers to gather clinical information and assess medical necessity.
• Collaborates with hospitals, care management, and other providers to meet clinical needs and prevent gaps in care.
• Acts as a resource to providers, explaining review processes and supporting access to services.
• Interprets clinical criteria, policies, benefits, and mandates accurately.
• May handle claims pricing, coding, and research for accurate benefit application.
• Meets departmental metrics and audit requirements, maintains compliance with standards, and supports training and special projects.

Level II:

• Suggests process improvements and handles more complex issues.
• Mentors staff and manages complex assignments, reviewing various care levels.

Level III:

• Provides leadership, updates policies, and handles escalations as a subject matter expert.
• Mentors staff, leads training, and supports medical projects.

Minimum Qualifications

• Associates degree and active NYS RN license required; Bachelors preferred.
• At least three years of clinical experience, with utilization management experience preferred.
• Proficient in Microsoft Office and understanding of coding standards.
• Knowledge of managed care benefit plans, government contracts, and strong communication skills.

Physical Requirements

• Ability to travel within service regions and work at a computer for extended periods.

We are committed to inclusion and encourage qualified individuals to apply. Our culture values compassion, pride, excellence, innovation, and fun. Compensation ranges from $60,410 to $117,622 depending on level and experience.

This job may be remote, decided case-by-case. All qualified applicants will receive consideration regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status.