Utilization Review Nurse - NYC, NY

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POST DATE 8/30/2016
END DATE 10/18/2016

AppleOne New York, NY

New York, NY
AJE Ref #
Job Classification
Full Time
Job Type
Company Ref #
Required Licenses/Certifications
Min Salary
Max Salary
Salary Unit
per year


My Client is looking for experienced clinicians to join the fast-growing Utilization Management team in our NYC headquarters. We're working to bring a new level of service to utilization review and ensure company members receive access to appropriate care in a timely, transparent way. As a Utilization Review Nurse, you will determine the medical appropriateness of inpatient and outpatient services by reviewing clinical information and applying evidence-based guidelines. You will also interact with company providers, members, and internal service team to obtain necessary information and communicate approval determinations.

Your primary responsibility in this role will be to conduct initial assessments of medical necessity for inpatient and outpatient services. In order to do so, you will need to:
? Collect relevant medical information (via telephone and fax) and apply the appropriate evidence-based guidelines and medical policy
? Meet required decision-making timeframes, including promptly triggering escalation for cases requiring physician review
? Clearly document all communication and decision-making within our utilization review tracking platform, ensuring a peer could easily reference and understand your decision
? Demonstrate the highest level of professionalism, accountability, and service in your interactions with company teammates, customer service, providers, and members
? Learn and use company tools and processes to perform and properly track all utilization reviews, as well to refer members for further care engagement when needed
? Develop a working familiarity with applicable regulatory and accreditation requirements
? Participate in quality improvement activities as requested
? Provide feedback into improving overall operations and member/provider experience
? Maintain continued professional growth and education to meet continuing education requirements and demonstrate knowledge & understanding of current nursing care practice

We are an equal employment opportunity employer and will consider all qualified candidates without regard to disability or protected veteran status.

Job Experience:

Required experience and qualifications include:
Active, unrestricted RN (BSN preferred) license in New York.
2 years UR experience at a managed care plan or provider organization
5 years Healthcare exp Hospital, ER, acute care or clinical practice.