Job Summary

A professional services firm needs applicants for an opening for a Remote New York Licensed Managed Care and Payer Utilization Management Nurse.

Candidates will be responsible for the following:

• Performing concurrent reviews of inpatient claims
• Performing prior authorization reviews for outpatient services
• Following and maintaining compliance with CMS requirements

Qualifications Include:

• Current unencumbered RN license in New York
• 2+ Utilization management experience with a health insurance company
• UM for Medicare Advantage, Managed Medicaid, Dual SNP Lines of Business, on the payer side
• 5+ years of acute clinical experience
• Proficiency using Milliman Care Guidelines (MCG) and/ or InterQual criteria
• Ability to facilitate empowerment for members/families