Summary: A leading Managed Care Health Company offers Medicaid, Medicare, and Marketplace health plans, focusing on high-growth segments in the managed care sector. Its passionate leadership leads by example, upholding core values and ensuring employee satisfaction while continually seeking innovative ways to provide quality healthcare to low-income individuals and families. With a nationwide presence, the company's diverse workforce embodies various cultures and backgrounds, fostering an inclusive and celebratory atmosphere within its employee family. 

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Job Summary:

In the role of a Utilization Management RN, you will be an integral member of our diverse healthcare team, dedicated to ensuring the smooth progress of patients along their care journey, aligning with appropriate admission criteria. Your expertise in Utilization Review processes will be pivotal in maintaining streamlined procedures that adhere to regulatory and reimbursement guidelines for a variety of payers, encompassing both commercial and governmental entities.

Key Responsibilities:

• Execute concurrent and ongoing Utilization Management assessments, meticulously tracking, evaluating, and reporting data.
• Assume a leadership role or actively participate in initiatives aimed at process enhancement, collaborating with cross-functional teams and departments.
• Efficiently manage a multifaceted workload within a dynamic, ever-changing regulatory landscape.
• Cultivate collaborative relationships with the Care team to facilitate timely patient transitions during their healthcare experience.

Job Requirements:

• Hold a valid PN or RN compact license 
• Possess an Associate's degree; Bachelor's degree is preferred.
• Accumulate 3-5 years of acute hospital experience along with 3-5 years of Utilization Management expertise.
• Prior hospital case management exposure is advantageous.
• Demonstrate proficiency in federal and state regulations (DOH, Medicaid/Medicare) and exhibit familiarity with third-party payers and the principles of managed care.

Salary Range: $70,000-$80,000

Come join our dynamic team and contribute to our mission of delivering efficient Utilization Management and patient-centric care.