Utilization Review Nurse

• RN- Utilization Review Nurse Inpatient *Hybrid
• Must reside within the New York Tri-State Area - NY, NJ, or CT

Come work for the leading, local managed care company - Village care!

• VillageCare is looking for a self-motivated and passionate RN as Utilization Review Nurse for a Full-Time position.
• This is an exciting and dynamic position from the comfort of your own home as you will be responsible for the assessment of member needs and identification of solutions that promote high quality and cost effective health care services.
• Some of your daily activities will include: Reviews planned, in process, or completed health care services to ensure medical necessity and effectiveness according to evidence-based criteria - prospective, concurrent and retrospective review.
• Frequently collaborates and communicates with physician peer reviewers and medical directors in determining coverage of requested services.
• Provide intervention and coordination to decrease delays and denials.
• Maintains timely, complete and accurate documentation in compliance with VCMAX policies and procedures.
• Support Quality and Performance Improvement Initiatives.
• Timely follow-up on results of denial and internal appeal reviews.
• We would like to speak to those who have a current unrestricted NYS RN license to practice professional nursing, URAC preferred.
• Seeking those who bring a BSN (advanced degree preferred), along with 2+ years of utilization review experience at a Managed Care Organization or Health Plan required.
• Working knowledge of Medicaid and/or Medicare regulations as well as coverage guidelines and benefit limitations.
• The ability to apply Interqual/ Milliman Care Guidelines and other applicable, evidenced-based clinical guidelines will be vital to this role.
• Must have a minimum of 1 year long term support service experience.
• Inpatient experience required.
• MLTC and Hospital/SNF experience required.

Must reside within the New York Tri-State Area - NY, NJ, or CT.

• There are many benefits to working for VillageCare.
• If you are someone who likes being part of a team, enjoys a highly competitive benefits package from world leading carriers and competitive compensation, than we would love to speak with you!