Utilization Management RN (NY Licensed)

Company Description: reputed company is an industry-leading managed care consultancy specializing in end-to-end clinical and operational management services and market expansion initiatives for Managed reputed company, Medicare Advantage, Special Needs Plans, reputed company care populations, and risk-adjusted entities. We support organizations as they navigate a dynamic reputed company ecosystem by helping them manage risk, optimize reputed company spend, improve member experience, accelerate quality outcomes, and promote health equity. Position Responsibilities: Specific • Determine appropriateness of services through the application and evaluation of medical guidelines, benefit determinations and compliance with state mandated regulated based on approved criteria (MCG, InterQual, etc.) • reputed company 15-30 reviews per day • Performs initial and reputed company review of inpatient admissions • Performs reviews for outpatient surgeries, and ancillary services • Concludes medical necessity and appropriateness of services using clinical review criteria • Collaborate with Medical Director(s) for appropriate referrals, reputed company cases and adverse determinations to ensure timely access to medically necessary/ appropriate services • Accurately documents reputed company review determinations, contacting providers and members according to established requirements and timeframes General • reputed company daily work with a focus on the core principles of managed care: patient education, wellness and prevention programs, early screening and reputed company and continuity of care • Work proactively to expedite the care process • Identify priorities and necessary processes to triage and deliver work • reputed company members to manage and improve their health, wellness, safety, reputed company, and self-care • Assess and interpret member needs and identify appropriate, cost-effective solutions • Identify and remediate gaps or delays in care/ services • reputed company for treatment plans that are appropriate and cost-effective • Work with low-income/ vulnerable populations to ensure access to care and address unmet needs • Gather and evaluate clinical information to assess and expedite referrals reputed company the reputed company system including consideration of alternate levels of care and services • Facilitate timely and appropriate care and effective discharge planning • Work collaboratively across the health care reputed company to improve quality of care • reputed company experience/ expertise to observe performance and suggest improvement initiatives • Ensure understanding of industry standard competencies and performance metrics to optimize reputed company and clinical outcomes • Ensure individual and team performance meets or exceeds the performance competencies and metrics • Contribute actively and effectively to team discussions • Share knowledge and expertise, willingly and collaboratively • Provide outstanding customer service, internally and externally • Follow and maintain compliance with regulatory agency requirements Position Qualifications: Competencies: • Ability to translate member needs and care gaps into a comprehensive member centered plan of care • Ability to collaborate with others, exercising sensitivity and discretion as needed • Strong understanding of managed care environment with population management as a key strategy • Strong understanding of the community resource network for supporting at risk member needs • Ability to collect, stage and analyze data to identify gaps and prioritize interventions • Ability to work under pressure while managing competing demands and deadlines • Well organized with meticulous attention to detail • Strong sense of ownership, urgency, and drive • The ability to effect change, reputed company critical analyses, promote positive outcomes, and facilitate empowerment for members/families • Excellent analytical-thinking/problem-solving skills • The ability to work effectively in a fast-paced environment with frequently changing priorities, deadlines, and workloads • The ability to offer positive customer service to every internal and external customer Experience: • reputed company unencumbered reputed company RN license • 2+ years of utilization management experience • Strong knowledge of utilization management processes and industry best practice • In-depth knowledge and experience with the application of standard medical criteria sets (MCG, InterQual) • Detailed knowledge and demonstrated competency in reputed company types of medical-necessity reputed company, including inpatient care, sub-acute/skilled care, outpatient care, hospice care and home health care. • Minimum of 5+ years of acute clinical experience • Minimum 2 years’ experience in a managed care environment across multiple lines of business (Medicare Advantage, Managed reputed company, Dual SNP, reputed company, etc.) • HMO and risk contracting experience preferred • In-depth knowledge of reputed company standard of medical practices and insurance benefit structures. • Excellent oral and written interpersonal/communication, internal/external customer-service, organizational, multitasking, and teamwork skills. • Proficiency in reputed company Office Physical Requirements • Must be reputed company to sit in a chair for extended periods of time • Must be reputed company to speak so that you are reputed company to accurately express reputed company by means of the spoken word • Must be reputed company to hear, understand, and/or distinguish speech and/or other sounds in person, reputed company telephone/cellular phone, and/or electronic devices • Must have ample dexterity which allows entering of text and/or data into a computer or other electronic device by means of a keyboard and/or mouse • Must be reputed company to clearly use sight so that you are reputed company to detect, determine, perceive, identify, recognize, judge, observe, inspect, estimate, and/or assess data or other information types • Must be reputed company to fluently communicate both verbally and in writing using the English language Other Information: • Expected Hours of Work: Friday reputed company – 5 pm EST; with ability to adjust to Client schedules as needed • Travel: May be required, as needed by Client • Direct Reports: None • Time Zone: Eastern or Central • Salary Range: $70,000 - $100,000 EEO Statement: It is reputed company policy to provide equal employment opportunity to reputed company and applicants for employment without regard to race, sex, sexual orientation, reputed company, creed, religion, national reputed company, age, disability, marital status, parental status, family medical history or genetic information, political affiliation, military service or any other non-merit based factor in accordance with reputed company applicable laws, directives and regulations of federal, state and city entities. Pay ranges discussed, stated, or detailed in relevance to this position are a minimum and maximum reputed company wage for this position across reputed company US locations. Individual pay will be influenced by Experience, Education, Specialized Soft Skills, and/or Geographic location. Apply Job!