Utilization Management NurseSanta Barbara Cottage Hospital • New York, New York, United States
Dieses Stellenangebot ist nicht mehr verfügbar
Utilization Management Nurse
Santa Barbara Cottage Hospital
- New York, New York, United States
- New York, New York, United States
Über
Primary Responsibilities
Performs clinical utilization reviews using evidence based guidelines, policies and nationally recognized clinical criteria and internal policies/procedures.
Identifies potential Third-Party Liability and Coordination of Benefit Cases and notifies appropriate parties/departments.
Collaborates with healthcare partners to ensure timely review of services and care.
Provides referrals to Case management, Disease Management, Appeals & Grievances, and Quality Departments as needed.
Develop and review member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards.
Identifies potential quality of care issues, service or treatment delays and intervenes as clinically appropriate.
Triages and prioritizes cases and other assigned duties to meet required turnaround times.
Prepares and presents cases to Medical Director (MD) for medical director oversight and necessity determinations.
Communicates determinations to providers and/or members in compliance with regulatory and accreditation requirements.
Duties as assigned.
Essential Qualifications
Current Licensed Practical Nurse (LPN) with state licensure. Must retain active and unrestricted licensure throughout employment.
Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint)
Must be able to work independently.
Must be detail oriented and have strong organizational and time management skills.
Adaptable to a high pace and changing environment- flexibility in assignment.
Proficient in Utilization Review process including benefit interpretation, contract language, medical and policy review.
Proficient in MCG and CMS criteria sets
Experience with both inpatient and outpatient reviews including Behavioral Health, DME, Genetic Testing, Clinical Trials, Oncology, and/or elective surgical cases preferred.
Working knowledge of URAC and NCQA.
2+ years’ experience in a UM team within managed care setting.
3+ years’ experience in clinical nurse setting preferred.
TPA Experience preferred.
#J-18808-Ljbffr
Sprachkenntnisse
- English
Hinweis für Nutzer
Dieses Stellenangebot wurde von einem unserer Partner veröffentlicht. Sie können das Originalangebot einsehen hier.