Utilization Review Nurse

Village Care; New York (NY); Remote; USD 60,000 - 90,000; Full time

Job summary

Join a leading managed care company as a Utilization Review Nurse in a fully remote role! This dynamic position allows you to assess member needs and identify solutions for high-quality, cost-effective health care services. You will collaborate with medical professionals, ensure compliance with guidelines, and support quality improvement initiatives. With a competitive benefits package and a focus on teamwork, this opportunity is perfect for passionate RNs looking to make a difference in the health care industry while working from the comfort of their home.

Benefits

PTO package

10 Paid Holidays

Medical/Dental/Vision

Education Reimbursement

Retirement Savings 403(b)

Life & Disability

Commuter Benefits

Paid Family Leave

Additional Employee Discounts

Qualifications

• Current unrestricted NYS RN license required.
• 2+ years of utilization review experience at a Managed Care Organization.

Responsibilities

• Review health care services for medical necessity and effectiveness.
• Collaborate with physicians on coverage of requested services.
• Maintain accurate documentation in compliance with policies.

Skills

Utilization Review

Nursing

Interqual Guidelines

Medicaid Regulations

Medicare Regulations

Documentation

Education

BSN

NYS RN License

Job description

RN- Utilization Review Nurse

Inpatient

*Full Time - 100% Remote Opportunity*

COME WORK FOR THE LEADING, LOCAL MANAGED CARE COMPANY - VILLAGE CARE!

VillageCare is looking for a self-motivated and passionate RN as Utilization Review Nurse for a Full-Time position. This is an exciting and dynamic position from the comfort of your own home as you will be responsible for the assessment of member needs and identification of solutions that promote high quality and cost effective health care services. Some of your daily activities will include:

• Reviews planned, in process, or completed health care services to ensure medical necessity and effectiveness according to evidence-based criteria - prospective, concurrent and retrospective review.
• Frequently collaborates and communicates with physician peer reviewers and medical directors in determining coverage of requested services.
• Provide intervention and coordination to decrease delays and denials.
• Maintains timely, complete and accurate documentation in compliance with VCMAX policies and procedures.
• Support Quality and Performance Improvement Initiatives.
• Timely follow-up on results of denial and internal appeal reviews.

We would like to speak to those who have a current unrestricted NYS RN license to practice professional nursing, URAC preferred. Seeking those who bring a BSN (advanced degree preferred), along with 2+ years of utilization review experience at a Managed Care Organization or Health Plan required. Working knowledge of Medicaid and/or Medicare regulations as well as coverage guidelines and benefit limitations. The ability to apply Interqual/ Milliman Care Guidelines and other applicable, evidenced-based clinical guidelines will be vital to this role. Inpatient experience required. MLTC and Hospital/SNF experience required.

Must reside within the New York Tri-State Area - NY, NJ, or CT.

There are many benefits to working for VillageCare. If you are someone who likes being part of a team, enjoys a highly competitive benefits package from world leading carriers and competitive compensation, than we would love to speak with you!

• PTO package, 10 Paid Holidays, Personal and Sick time, Medical/Dental/Vision, HRA/FSA, Education Reimbursement, Retirement Savings 403(b), Life & Disability, Commuter Benefits, Paid Family Leave, Additional Employee Discounts

VillageCare offers a wide range of at-home and community-based services, as well as managed long-term care options that seek to match each individual's needs to help them attain and maintain the greatest level of independent living possible. We are committed to superior outcomes in quality health care.

VillageCare is an Equal Opportunity Employer.