Utilization Review Nurse

The UM Nurse manages providers, members, or care manager generated requests for medical services and renders clinical determinations in accordance with Hamaspik Choice policies as well as applicable state and federal regulations. UM Nurse delivers timely notification detailing Hamaspik Choice clinical decisions. Participates in UM review process of claims.

Essential Responsibilities:

· Reviews planned, in process, or completed health care services to ensure medical necessity and effectiveness according to evidence-based criteria.

· Utilizes Plan approved evidence based data set to make decisions

· Able to match member care needs to available resources at the appropriate level of care and make adjustments if necessary

· Consults with Medical Director to determine the appropriate next steps for services that require further review

· Assures that case documentation for each decision is complete, including related correspondence.

· Maintains timely, complete and accurate documentation in compliance with Hamaspik Choice policies and procedures

· Gathers and summarizes data for reports

· Support Quality and Performance Improvement Initiatives

· Conducts utilization review – prospective, concurrent and retrospective

· Participates in appeal process

Specific Knowledge, Skills, and Abilities:

· Valid New York State, unrestricted, RN license

· Bachelor’s Degree (BSN) preferred

· MLTC or Medicare experience (preferred)

*Not a remote position*