The Specialist Use Management Nurse assists in ensuring that quality, cost- effective care is delivered to members of all product lines of HealthNow NY Inc. Assists in containing the cost of health care services by detecting, resolving and preventing improper utilization of member benefits by applying Utilization processes such as prior authorization for inpatient/ outpatient services/ appeals / claims/ inquiry review under the supervision of the Manager or Supervisors of that department. Maintains adherence to established Policy and Procedures, Quality Improvement processes and Compliance Standards.
Primary Job Duties:
- Performs either pre or post service review for medical necessity utilizing criteria, medical policy and submitted medical information. Prepares any case that does not meet medical necessity to submit to a Medical Director. Post review, informs member, MD and/or facility of the decision in a written document and/or an oral response. May prepare various correspondences including Initial Adverse Determination, Final Adverse Determination, approval or a Last Covered Day within required time frame guidelines. Utilizies multi computer applications to effectively perform duties.
- Triages provider requests to comply with regulatory requirements; applies appropriate timeframes to meet regulatory requirements for requesting medical records or sending out the decisions. Maintains compliance with HIPAA (Health Insurance Portability and Accountability Act) for all work.
- Utilizes and applies knowledge and understanding of CPT procedure codes, HCPC (DME) codes and ICD (Diagnosis ) codes in performance of duties.
- Travel and communication with facilities and Provider community, in the course of duties, as necessary.
- Performs other related duties as required.
Bachelors Degree (Nursing)
- Excellent time management skills
- Public communication and presentation skills
- Computer applications; including , but not limited to: MS Word, MS Excel, MS PowerPoint, MS Access, Visio, Lotus Notes, Internet
- Excellent organizational skills and attention to detail
- Excellent verbal and written communication skills
- Strategic thinking/planning skills and ability to work effectively with minor supervision
- Polished, professional image and reputation. Demonstrated personal accountability
- Must be able to work in a fast-paced environment with daily work processing deadlines
- High degree of business maturity and demonstrated confidentiality
- High energy level and ability to project enthusiasm
- Persuasive communication style
- Preferred experience in utilization management, managed care, health insurance industry, and the provider community
- NOTE: Valid drivers license and acceptable driving history required due to travel involved with this position (DMV check will be conducted to review candidate's driving record) IF applicable to the job responsibilities, i.e., on-site
A minimum of two years-clinical experience required.
Associates Degree (Nursing)
A minimum of three years-clinical experience, required.
- Irregular hours
- Must be able to accommodate alternate shifts/days
- Must be able to work in an office environment
- Must be able to occasionally attend off-site meetings, events, conferences
- Must have ability and access to work from remote location such as home
- Must be able to accommodate local travel. Valid drivers license and acceptable driving history required due to travel involved with this position (DMV check will be conducted to review candidate's driving record)
- Repetitive Motion
- Prolonged Sitting
- Manual Dexterity Req: Eye-hand coordination and manual dexterity sufficient to effectively use a computer with all its components for prolonged periods of time and for the majority of required tasks
- Manual Dexterity Req: Eye-hand coordination and manual dexterity sufficient to effectively utilize various office equipment (phone, computer, fax machine, printer, copier, filing cabinet, etc)
- Vision Req: Close vision (clear vision at 20 inches or less)
- Vision Req: Distance (clear vision at 20 feet or more)
- Physical Effort: Minimum; typical of most office work. Mostly sedentary work.
- Weight: Occasionally lift/carry under 10 lbs.
- Registered Nurse
- Driver's License/DMV Check Required
HealthNow New York Inc. - 19 months ago