Utilization Review RN

CareConnect; Greenvale (NY); On-site; USD 70,000 - 90,000; Full time

Job summary

CareConnect in Greenvale, New York is looking for a qualified candidate to oversee utilization management activities. The role involves coordinating clinical compliance and ensuring timely case management for patients while working closely with healthcare teams.

The ideal candidate must have a Bachelor’s Degree in Nursing and five years of clinical experience. The job aims to enhance patient outcomes and provide education for better self-care and advocacy.

Qualifications

• Graduate from an accredited School of Nursing.
• BSN Degree required within five years of hiring if hired after September 2010.
• Minimum of five years clinical experience.

Responsibilities

• Perform medical necessity reviews for selected procedures.
• Provide timely case screening and referrals.
• Collaborate with healthcare teams for optimal outcomes.
• Identify discharge needs and facilitate timely discharges.

Skills

Case management

Clinical compliance

Communication

Education

Bachelor's Degree in Nursing

Job description

The first commercial provider-owned health plan in New York State, CareConnect was created by Northwell Health, formerly North Shore-LIJ Health System to make it easy for people to get and stay healthy. Its innovative model is designed to provide access to care that’s both excellent and affordable. CareConnect was founded in 2013 and offers a variety of plans for individuals, families and businesses. CareConnect’s network has grown to more than 20,000 providers at hospitals and physician practices throughout downstate New York.

Job Description

Reviews and coordinates prospective, concurrent and retrospective activities related to utilization. Monitors documentations for accuracy and clinical compliance. Organizes and coordinates activities within the organization in accordance with standards of State and Federal regulations; and in accordance with accreditation and other guidelines.

• Performs medical necessity reviews for selected procedures and services.
• Provides timely and thorough case screening to identify case management needs and make appropriate referrals to case managers.
• Collaborates with members/designees, families and members of the health care team to maximize outcomes.
• Identifies discharge needs and collaborates with health care providers to facilitate a timely discharge to an appropriate level and location of care.
• Educates providers and members to promote self-care and self-advocacy.
• Realizes positive outcomes in terms of the quality, safety and cost-effectiveness of health care services provided.
• Responds to outstanding utilization management issues and inquiries made via overnight voicemail and/or emails.
• Develops and maintains cooperative relationships with other parts of the organization. Consults with colleagues/experts as needed.
• Performs related duties, as required.

Qualifications

Graduate from an accredited School of Nursing . Bachelor’s Degree in Nursing, preferred.

Must be enrolled in an accredited program within 24 months of employment, if hired after September 1, 2010 and obtain a BSN Degree within five (5) years of employment date.

Minimum of five (5) years clinical experience, required. Previous experience in case management, disease management, quality management or patient education, preferred.