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Case Management / UM Review Registered Nurse (RN)

Location : Buffalo, NY
Job Type : Direct
Hours : Full Time
Required Years of Experience : 3
Travel : No
Relocation : No
Job Industry : Managed Care

Job Description :
Case Management / UM Review Registered Nurse (RN)

 

A large, national managed care company is looking to add a Comprehensive Care UM Registered Nurse to their team.  

 

Description:



  • Provides comprehensive care management services for external clients and for all lines of business in conjunction with strategic business partnerships, all applicable regulatory guidelines and any applicable specific state requirements.



  • Comprehensive care management functions include Utilization Management, Case Management, Disease Management and Cost Containment, providing the continuum of health services necessary to improve health, prevent and control disease and have a measurable impact on health related costs.



  • Performs a complete review for medical necessity, pre service, post service, or concurrent, using criteria, medical policy and submitted medical information, with Medical Director review as indicated.



  • Provides cost effective claim negotiation services with out-of-network (OON) providers for recertified medically necessary health services, in coordination with the client, and as per plan provisions. 



  • Facilitates and provides adverse determination case appeal reviews as requested, and as appropriate, based on a member's appeal rights, plan provisions and applicable regulatory guidelines. 



  • Acts as an advocate and liaison to meet a member's individual health care needs, the RN will assess, plan, implement, coordinate, monitor and evaluate options and services.


 

Required Qualifications :
Case Management / UM Review Registered Nurse (RN)



Minimum Requirements:


  • CCM designation required within 3 years of accepting position. 



  • 3 years clinical experience, 1 year of which must be in a hospital setting. 



  • NY state RN license in good standing required; multi-state RN licensure preferred.



  • Bilingual ability preferred, fluent in Spanish.



  • Bachelor's Degree preferred.

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