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! Responsibilities 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. Qualifications 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. 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 VillageCare offers a wide range of at-home and community-based services, as well as managed long-term care options that seek to match each individual's needs to help them attain and maintain the greatest level of independent living possible. We are committed to superior outcomes in quality health care. VillageCare is an Equal Opportunity Employer. Salary: $95000 - $105000 per year #J-18808-Ljbffr