Remote – UM RN – Utilization Management – LTSS – New York

Compass Healthcare Consulting & Placement is conducting a search for an experienced UM RN, Utilization Management, Registered Nurse for a large Managed Care Plan located in New York. Position is fully remote, work from home! Qualified candidates will have prior LTSS, MLTC DME Utilization Management experience within a Managed Care setting, LTSS, MLTC MAP, will have a NYS Registered Nurse License, familiar with Interqual Guidelines and a desire to join a great team!

UM RN – Utilization Management – Managed Care

Under general supervision, provides professional assessment, planning, coordination, implementation and reporting of complex clinical data and supports the operations of the Utilization Management functions within healthcare programs.

Responsibilities Include:

• Performs utilization review in accordance with all regulations.
• Maintains compliance with regulation changes affecting utilization management. Reviews participants’ records and evaluates patient progress.
• Performs continuing review on medical records and identification and need of on-going hospitalization.
• Obtains and reviews the necessary medical reports and subsequent treatment plan requests to conduct the review.
• Reviews and validates physician’s orders, reports progress and unusual occurrences on participants. Ensures appropriate and cost-effective healthcare services to participants.
• Documents review information in the computer. Communicates results to claims adjusters. Enters billing information for services.
• Prepares information for notification letters for providers and employees. Receives and processes requests for the appeal of denials.
• Responds to complaints per UM guidelines. Maintains Utility review and appeal logs, as needed, by jurisdiction.
• Analyzes patient records and participates in interdisciplinary collaboration with professional staff.
• Facilitates educational programs and advises physicians and other departments of regulations affecting utilization management.
• Consults with Social Services Departments regarding the level of nursing care and collaborates with other departments in the evaluation of projects affecting discharge plans.
• Supports clinical improvement activities of core business groups by providing a quality review. Records and reports all information within the scope of authority
• Performs administrative duties; receives, logs in and files a variety of reports, client charts, client interactions, and other documents.
• Performs other duties as assigned or required.

Skills/Abilities:

• Knowledge of modern nursing principles, techniques, and procedures for the care of participants.
• Knowledge of medical terminology, anatomy, physiology, and concepts of disease.
• Knowledge in conducting and reviewing medical record for medical necessity.
• Knowledge of regulations as set forth by The Centers for Medicare Medicaid Services
• Skill in providing effective nursing care, assessing patient situations and taking effective courses of action.
• Skill in operating a personal computer utilizing a variety of software applications.
• Strong written and oral communication skills