We are seeking a Utilization Review Nurse (LVN/RN) with strong clinical judgment to join our team at a Managed Care Organization in New York. In this role, you will play a pivotal role in ensuring high-quality, cost-effective care for patients, facilitating their journey towards maximum medical improvement while receiving medically necessary treatment. As a key member of our team, you will assess the appropriateness, quality, and medical necessity of referral requests based on established guidelines.

This is remote position only for the New York Tri-State area

Responsibilities:

• Evaluate the appropriateness, quality, and medical necessity of referral requests, utilizing pre-established guidelines.
• Provide utilization management services to patients of Coordinated Health Care employer groups with catastrophic illnesses and/or injuries.
• Serve as a clinical resource for various departments within the company, including utilization review, patient services, disease management, and sales.
• Handle cases in pre-authorization areas, skilled nursing facility review, or concurrent review as assigned.

Requirements:

• Active and Unrestricted LVN or RN licensure in the state of New York.
• Previous LVN/RN experience with Utilization Management (UM) preferred.
• General knowledge of UM and Managed Care is desirable.
• Familiarity with InterQual guidelines is a plus.
• Experience in meeting deadlines by effectively prioritizing workflow is preferred.
• Physician group experience is advantageous.
• Thorough understanding of nursing requirements in a clinical setting.
• Proficiency in utilization management programs, including pre-set protocols and criteria.
• Knowledge of health plans, medical specialty procedures, and diagnoses.
• Familiarity with business practices and protocols, with the ability to access data and information using automated systems.
• Ability to read and interpret benefit contract specifications.
• Capability to work within an interdisciplinary structure, independently manage multiple priorities, and meet deadlines in a fast-paced environment.
• Aptitude for applying clinical judgment to complex medical situations and making prompt decisions.
• Strong organizational skills.
• Effective telephone and computer data entry skills are required.
• Ability to formulate ideas and solutions into appropriate questions, as well as assess and interpret verbal responses.
• Excellent communication skills for interacting with coworkers, members, their families, physicians, and healthcare providers are preferred.

Join our team and contribute to delivering exceptional healthcare services while promoting cost-effective care for patients in New York.