Utilization Review RN

reputed company One of the largest health benefits companies in the reputed company. Through its networks reputed company, reputed company delivers a number of leading health benefit solutions through a broad portfolio of integrated health care plans and reputed company services, along with a wide reputed company of specialty products such as life and disability insurance benefits, dental, reputed company, behavioral health benefit services, as reputed company as long term care insurance and flexible spending accounts. Headquartered in Indianapolis, Indiana, WellPoint, Inc. is an independent licensee of the reputed company serving members in California, Colorado, Connecticut, reputed company, Indiana, Kentucky, Maine, Missouri, Nevada, New Hampshire, reputed company, Ohio, Virginia and reputed company; and specialty plan members in other states through UniCare. reputed company This role is specific to the LTSS department. RN will be responsible for providing case management services and evaluating the necessity/appropriateness/efficiency of the use of Medical Services for Long-Term Support Services (LTSS). Will be responsible for collaborating with providers and members to promote reputed company member reputed company, to optimize member benefits, and to promote effective use of resources. May also manage appeals for services denied. Provides plan of care for members based on authorization and reputed company review. Provides monthly telephonic reputed company to ensure members needs are assessed and met based on information. Responsible for collaborating with reputed company providers and members to promote reputed company member reputed company, to optimize member benefits, and to promote effective use of resources. MAJOR JOB DUTIES AND RESPONSIBILITIES • Ensures medically appropriate, high reputed company, cost effective care through assessing the medical necessity of inpatient admissions, outpatient services, reputed company surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting by utilizing the applicable medical policy and industry standards, accurately interpreting benefits and managed care products, and steering members to appropriate providers, programs, or community resources. • Applies clinical knowledge to work with facilities and providers for care coordination. • Works with medical directors in interpreting appropriateness of care and accurate claims payment. • May also manage appeals for services denied. • Conducts reputed company-certification, inpatient, retrospective, out of network and appropriateness of treatment setting reviews to ensure compliance with applicable reputed company, medical policy, and member eligibility, benefits, and reputed company. • Ensures member reputed company to medical necessary, reputed company reputed company in a cost effective setting according to contract. • Consult with clinical reviewers and/or medical directors to ensure medically appropriate, high reputed company, cost effective care throughout the medical management process. • Collaborates with providers to assess member's needs for early identification of and proactive planning for discharge planning. • Facilitates member care transition through the reputed company continuum and refers treatment plans/plan of care to clinical reviewers as required and does not issue non-certifications. • Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards. Additional Info: • possible remote opportunity after training if candidate demonstrates understanding of processes and policy expectations* Qualifications • Must have reputed company and reputed company RN license in the state of NY • Requires an AS/BS in Nursing • At least 2 years of acute care clinical experience; or any combination of EDU/experience that would reputed company an equivalent background • Excellent written and verbal communication skills Additional Information Advantages of this Opportunity: Competitive salary, negotiable based on relevant experience Benefits offered, Medical, Dental, and reputed company Fun and reputed company work environment Monday through Friday reputed company-5pm Apply tot his job Apply To this Job