Clinical Utilization Review Nurse

2 weeks ago

New York, New York, United States VNS Health Full time
Job Summary

VNS Health is seeking a skilled Registered Nurse to join our team as a Clinical Utilization Review Specialist. In this role, you will be responsible for resolving grievances, appeals, and external reviews for our Managed Long Term Care, Medicare Advantage, and Select Health product lines.

Key Responsibilities:

  • Investigate and review routine and complex situations, analyzing and solving problems related to medical necessity, quality of care, and long-term services and supports.
  • Consult with members, families, providers, and health plan departments as necessary to identify and communicate key points from details.
  • Coordinate the resolution of grievances and appeals according to defined processes and procedures, ensuring timely and accurate follow-up and documentation.
  • Review covered and coordinated services in accordance with established plan benefits, medical criteria, and regulatory requirements to ensure appropriate appeal resolution and execution of the plan's fiduciary responsibilities.
  • Collaborate with professionals, health plan departments, and third-party administrators to investigate and facilitate resolution of individual grievances and appeals.

Requirements:

  • License and current registration to practice as a registered professional nurse in New York State required.
  • Minimum three years progressive professional experience in healthcare, including a minimum of two years in a grievance and appeals or related area such as medical or utilization management required.
  • Proficient verbal/written communication skills and knowledge of Microsoft Office (Word and Excel) required.

About VNS Health

VNS Health is one of the nation's largest nonprofit home and community-based health care organizations. We innovate in healthcare for over 125 years, driven by our commitment to health and well-being. We help people live, age, and heal where they feel most comfortable, in their own homes, connected to their family and community.

Benefits

  • Guaranteed Hours
  • 401k retirement plan
  • Employee assistance programs
  • Dental benefits
  • Vision benefits
  • License and certification reimbursement
  • Life insurance
  • Discount program
  • Holiday Pay
  • Continuing Education
  • Wellness and fitness programs
  • Mileage reimbursement
  • Medical benefits
  • Benefits start day 1

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