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Case Manager/Utilization Review RN

Yoh PECK SLIP Full-Time
$85,000.00/ year
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Case Manager/Utilization Review RN  needed for a Direct Hire opportunity with Yoh’s client located in New York, New York area.

Working Conditions: Full time (M-F) Office Based

Top Skills Should You Possess:

  • A minimum of three years clinical experience as a Registered Nurse in a clinical setting required.
  • One year experience as a case manager or UM nurse in a payer or facility setting is also required.
  • Certified in Case Management or Utilization Management preferred

What You’ll Be Doing:

  • Visual and Auditory comprehension & function for written & verbal communication.
  • Manual  Dexterity with ability to use computers & other office equipment necessary to perform assigned tasks
  • Ability to access various settings, negotiate architectural barriers(i.e. stairs) in office &community settings
  • Ability to use Public Transportation to commute to work
  • Physical health sufficient to meet the ergonomic standards and demands of the position
  • Responsible  for  assuring  cost  efficient  outcomes  for  clients  and  evaluating  enrollee requests for inpatient and/or outpatient precertification/preauthorization for necessity.
  • The UM Nurse will coordinate, monitor, evaluate, and approve plans of care and/or service requests in accordance with guidelines.
  • The UM Nurse is able to work both independently and collaboratively with other members of the UM staff to assure timely and appropriate completion of assigned work in conformance with established departmental policies and standards.
  • Strictly observes NYCHSRO/MedReview policies regarding confidentiality of member information.
  • Conducts prospective, concurrent and retrospective utilization review for inpatient, observation or skilled nursing facility services as well as specific outpatient service requests
  • Knowledge of members’ benefits in order to work collaboratively with internal and external healthcare
  • providers to assure appropriate utilization of services and care transition. Will clarify member benefits as needed.
  • Works with physician reviewers (Medical Directors) and UM Staff, to perform first-level review of precertification requests, elective & urgent services.
  • Obtains clinical, functional and psychosocial information from the medical records telephonically or by fax in a collaborative effort with other health care professionals, member and/or family to determine medical necessity and benefit eligibility Requesting and obtaining relevant clinical information from appropriate provider, utilizing established policies, protocols, applicable regulatory review criteria and nationally accepted criteria for medical necessity determination.
  • Works with facility case management department or specifically assigned staff to develop appropriate discharge plans; implements and continually reassesses the discharge plan
  • Documentation of clinical review in the utilization management software system as well as necessary communications required for the members’ care.
  • Refers all cases that do not meet medical necessity criteria to a physician reviewer for consideration, ensuring the timely review of the referred case
  • Reviews physician reviewers’ determinations for appropriateness and completeness
  • Communicates determinations to providers and members telephonically and in writing, adhering to corporate/department policy and regulatory and URAC guidelines
  • Follows the Case Management Standards of Practice, Ethical Standards, department policies and procedures, and compliance regulations for reviewing and managing case management events (LPN, in collaboration with RN)  
  • Will check voicemail and e-mails at regular intervals throughout the day and returns calls/messages within the same day of receipt
  • Provides on-call coverage and performs other responsibilities as assigned by department management team

What You Need to Bring to the Table:

  • Graduate from an accredited school of nursing. Associates or Bachelor’s degree in nursing, or Bachelor’s in an appropriate related field.
  • An active and unrestricted license as a registered nurse (RN)in New York
  • A minimum of three years clinical experience as a Registered Nurse in a clinical setting required. One year experience as a case manager or UM nurse in a payer or facility setting is also required.
  • Certified in Case Management or Utilization Management preferred

What’s In It For You?

  • Weekends and holidays off
  • Join Yoh’s extensive talent community that will provide you with access to Yoh’s vast network of opportunities.
  • Direct deposit & weekly epayroll

Opportunity is Calling, Apply Now!

Recruiter: Tina Pugliese

Phone: 215-656-2646

Email: URL blocked - click to apply


Yoh makes finding and applying for jobs simple. Partner with Yoh to find the right opportunities across multiple industries in the US and UK. Find out more URL blocked - click to apply!

Yoh, a Day & Zimmermann company, is an Equal Opportunity Employer, M/F/D/V. URL blocked - click to apply to contact us if you are an individual with a disability and require accommodation in the application process.

 

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Job ID: BHJOB18230_235988

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