Utilization Review Nurse
Location: Bronx New York
Description: Affinity Health Plan is currently seeking to employ Utilization Review Nurse right now, this job will be placed in New York. For detail informations about this job opportunity kindly read the description below. Open Positions- Utilization Review Nurse
Affinity Health Plan, an independent, growing, not-for-profit managed care company designed specifically to serve the needs of low-income New Yorkers, needs a Utilization Review Nurse who will conduct reviews of current inpatient services, and determine medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination in accordance with Utilization Management policies and procedures.
Your responsibilities will include, but are not limited to:
Perform utilization management, utilization review, or concurrent review (on-site at a hospital, or telephonic inpatient care management)
Communicate directly with physician providers/designees when appropriate to gather all clinical information to determine the medical necessity of requested healthcare services
Maintains courteous, professional attitude when working with Affinity staff, hospital and physician providers, and members
Collect pertinent clinical information and documents all UM review information using the appropriate software system
Determine medical appropriateness of services following evaluation of medical and benefit determination guidelines
Communicate directly with appropriate internal staff regarding all inpatient cases and outpatient/ambulatory requests for health care services that do not meet medical necessity or appropriate level of care and out of network transfer issues
Manage assigned workload within established performance standards
Follow relevant client time frame standards for conducting and communicating UM review determination
Maintain and submit reports and logs on review activities as outlined by the UM program operational procedures
Maintain an active role in assuring the continuity of care for all inpatients through early discharge planning and working with hospital discharge planners and health plan social workers or other staff in the early identification of potential home care candidates or less restrictive level of care placement
Manage medical benefits resources effectively and efficiently while ensuring quality care is provided
Contribute to MM program goals and objectives in containing health care costs and maintaining a high quality medical delivery system through the program procedures for conducting UM activities
Participate in a multi-disciplinary team approach to address member needs from the acute care phase through the post-acute care phase
Identify and coordinate quality of care issues or trends with the Quality Management department
Demonstrate proficiency with the principles and methodologies of process improvement. Apply these in the execution of responsibilities in support of a process focused approach.
Perform other duties as necessary or assigned
Requirements for this position include:
Registered Nurse or Licensed Practical Nurse with current, unrestricted, licensure required for state of New York
Associates degree in Nursing required; BSN preferred
3+ years Clinical experience and 2 or more years experience working in utilization management required
Experience working in Medicaid and/or Medicare managed care, including regulatory and compliance requirements strongly preferred
Experience with Milliman guidelines preferred
Proficiency in software applications that include, but are not limited to, Microsoft Word, Microsoft Excel, Microsoft PowerPoint and Outlook required
Ability to work with minimal guidance; seeks guidance on only the most complex tasks
Problem solving skills; the ability to systematically analyze problems, draw relevant conclusions and devise appropriate courses of action
Excellent verbal and written communication skills; ability to speak clearly and concisely, conveying complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others.
Advanced interpersonal (e.g., mediating, counseling, mentoring, influencing), negotiating and management skills required to manage critical internal and external relationships and activities that are diverse and complex. Ability to collaborate constructively with others within and outside the organization.
Ability to work resourcefully and creatively, to think independently, and to exercise sound judgment in a complex and dynamic environment.
Commitment to the corporate mission, vision, and values.
High level of integrity as demonstrated by a) appropriate treatment of confidential information, b) adherence to policies, procedures, rules and regulations, c) professional conduct in dealing with persons internal and external to the organization, and d) sensitivity to the populations served by Affinity and the providers with which Affinity works.
If you meet or exceed these qualifications and are interested in this position, please respond by sending an email with your resume to jkjobs@affinityplan.org with the position title in the subject line. You can also fax your resume to 718-794-7846, stating that you are applying for this position on the fax cover sheet. We are an Equal Opportunity/AA Employer. Only qualified applicants will receive a response.
No agency responses, please.
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If you were eligible to this job, please email us your resume, with salary requirements and a resume to Affinity Health Plan.
If you interested on this job just click on the Apply button, you will be redirected to the official website
This job starts available on: Sat, 21 Jul 2012 10:10:21 GMT