Utilization Management RN: Care Reviewer & Advocate

Excellus BCBS; Jamestown (NY); Hybrid; USD 62,000 - 107,000; Full time

Benefits offered by this job

Group health and/or dental insurance

Retirement plan

Wellness program

Paid time away from work

Paid holidays

Job summary

Excellus BCBS in the United States is seeking a Utilization Management professional to coordinate clinical reviews, ensure compliant service utilization, and collaborate with care teams to address member needs.

The role requires an active NYS RN license, a relevant degree, 3+ years of UM experience, and proficiency with Microsoft Office. Strong communication and multitasking abilities are essential for success in this position.

Qualifications

• Associates degree and active NYS RN license required.
• Bachelors degree preferred.
• Minimum of three (3) years of clinical experience; Utilization Management experience preferred.
• Proficiency with Microsoft Office Suite.
• Understanding of coding standards.
• Experience interpreting managed care contracts (Medicare/Medicaid) preferred.
• Strong written and verbal communication skills.
• Ability to multitask and balance priorities.

Responsibilities

• Perform pre-service, concurrent and post-service clinical reviews to determine service appropriateness.
• Plan, implement and document utilization management activities.
• Assess medical necessity and advocate for members.
• Collaborate with hospital, home care, care management and other providers.
• Explain processes to providers and obtain case management support.

Skills

Communication skills

Multitasking

Independent work

Microsoft Office

Education

Associates degree

Bachelors degree

Tools

Microsoft Office

Job description

Excellus BCBS in the United States is seeking a Utilization Management professional to coordinate clinical reviews, ensure compliant service utilization, and collaborate with care teams to address member needs.

The role requires an active NYS RN license, a relevant degree, 3+ years of UM experience, and proficiency with Microsoft Office. Strong communication and multitasking abilities are essential for success in this position.