VillageCare - New York, NY
posted 3 days ago
About the position
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.
Responsibilities
- 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.
Requirements
- Current unrestricted NYS RN license to practice professional nursing
- 2+ years of utilization review experience at a Managed Care Organization or Health Plan
- Working knowledge of Medicaid and/or Medicare regulations as well as coverage guidelines and benefit limitations
- Ability to apply Interqual/ Milliman Care Guidelines and other applicable, evidenced-based clinical guidelines
- Inpatient experience required
- MLTC and Hospital/SNF experience required
Nice-to-haves
- BSN (advanced degree preferred)
- URAC certification preferred
Benefits
- 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
