Utilization Review Nurse

Job Title RN-Utilization Review Nurse (Hybrid, Inpatient) Overview VillageCare is looking for a self‑motivated and passionate RN as Utilization Review Nurse for a full‑time position, working from home. The RN will assess member needs and identify solutions that promote high quality and cost‑effective health care services. Responsibilities Review 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 collaborate and communicate with physician peer reviewers and medical directors to determine coverage of requested services. Provide intervention and coordination to decrease delays and denials. Maintain timely, complete and accurate documentation in compliance with VCMAX policies and procedures. Support Quality and Performance Improvement Initiatives. Follow up on results of denial and internal appeal reviews in a timely manner. Qualifications Current unrestricted NYS RN license; URAC preferred. BSN; advanced degree preferred. Minimum 2 years of utilization review experience at a Managed Care Organization or Health Plan. Working knowledge of Medicaid and/or Medicare regulations, coverage guidelines and benefit limitations. Ability to apply InterQual / Milliman Care Guidelines and other evidence‑based clinical guidelines. Minimum 1 year of long‑term support service experience. Inpatient experience required. MLTC and Hospital/SNF experience required. Benefits PTO package, 10 Paid Holidays, Personal and Sick time. Medical/Dental/Vision, HRA/FSA, Education Reimbursement. Retirement Savings 403(b), Life & Disability. Commuter Benefits, Paid Family Leave, Additional Employee Discounts. Other Information Must reside within the New York Tri‑State Area - NY, NJ, or CT. Equal Opportunity Employer VillageCare is an Equal Opportunity Employer. #J-18808-Ljbffr