New York Licensed Utilization Review Nurse

Job Summary

A company is looking for a Utilization Review Nurse.

Key Responsibilities

• Review health care services for medical necessity and effectiveness through evidence-based criteria
• Collaborate with physician peer reviewers and medical directors on service coverage decisions
• Maintain documentation compliance and support quality improvement initiatives

Required Qualifications

• Current unrestricted NYS RN license
• BSN required; advanced degree preferred
• 2+ years of utilization review experience in a Managed Care Organization or Health Plan
• Knowledge of Medicaid and/or Medicare regulations and coverage guidelines
• Inpatient experience required; MLTC and Hospital/SNF experience preferred