Utilization Review Nurse Jobs

The Utilization Review Nurse assists the utilization review process taking on various tasks including data collection of demographic, claim and medical information; analysis; and outcomes reporting. Utilizes standards of care, evidence based practices, Medicare and Medicaid and organizational coverage guidelines to assure members receive high quality, cost efficient health care and services to meet their long term home and community based needs. Performs utilization review in accordance with all state mandated regulations.

This position is Full-Time, Monday through Friday, 8a-4:30p, and can be semi-remote with periodic travel to our Syracuse Office.

Performance Responsibilities and Standards:

• Creates and facilitates educational programs.
• Performs concurrent, prior service authorizations and retrospective reviews
• Assist with the development of coverage policy guidelines for MLTC services.
• Participates in interdisciplinary collaboration with professional staff.
• Assist with the review of member usage patterns for medical necessity and appropriateness.
• Other duties as assigned
• Prepares for and attends Fair Hearings.
• Tracks and analyzes service utilization patterns monthly and compares to regional benchmarks
• Process Notice of Action letters
• Performs continuing review of medical records and supporting documentation for medical necessity where appropriate.
• Reviews appeals and provides notice of determination.
• Analyze per member per month (PMPM) data
• Receives and responds to Office of Temporary and Disability Assistance (OTDA) notifications of Fair Hearings
• Identifies and collaborates with UR Manager on individual cases
• Identifies and collaborates with UR Manager on trends in usage patterns.

Job Qualifications:

• Five or more years of home health care or long term care experience strongly preferred.
• Three or more years of utilization management or quality improvement experience preferred.
• Current NYS RN licensure, BSN preferred.

Professional competencies, skills and abilities:

• Successfully manage conflict and negotiate a win win solution
• Ability to be non-judgmental
• Strong organizational, prioritizing and delegation skills
• Advocacy focused
• Excellent relationship management skills
• Computer literacy with Microsoft office products
• Strong communication skills written and verbal
• Demonstrated ability to problem solve complex, multifaceted situations
• Abstract thinking

Physical Requirements:

• Bloodborne Pathogens Exposure Determination Category: Category III
• Speech, visual, and hearing ability sufficient to express and comprehend written and verbal communication
• Pushing, pulling, reaching, kneeling
• Ability to sit 90% of the day
• Frequent sitting, standing, walking

Compensation & Benefits:

Competitive Salary with:

• Employee Assistance Program (EAP)
• Much More!!
• Exceptional work/life balance - no rotating shifts
• Paid Time Off, Holidays, and Extended Sick Leave
• Short/Long term Disability
• Employee Recognition Platform
• Medical, Dental, Vision plans
• Partially funded HSA
• Tuition Reimbursement for BSN after 6 months of employment
• 401K with generous Employer match

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About Nascentia Health:

Nascentia Health is leading the way in home care, post acute care and long-term community health. A healthcare system without walls, Nascentia is an innovator in the concept of healthcare, truly focused on the patient as a whole. By serving people in their homes, Nascentia Health is able to provide true holistic care. We can address immediate needs, help support positive long term medical and lifestyle choices that provide for better outcomes, leverage cutting edge in-home care technologies, and help avoid unnecessary visits to busy healthcare facilities.

Our employees are our greatest asset. They work hard every day to make our system amazing and are dedicated to our mission of being the premier home and community-based care system for the regions we serve. We want everyone to love what they do, be excited about coming to work, and take pride in being part of our team.

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Nascentia Health is an Equal Opportunity Employer (EOE)

Employment is contingent upon negative results of a pre-hire drug screen