Utilization Review Nurse - PRIDE Health : Job Details

Job Description: Title: Care Manager - ED Shift: 9am-5pm Hybrid (40 hours weekly) Location: New York, NY 10037 Duration: 13 Weeks (Possible Extension) Pay: $52/hr. Job Summary: - Review and evaluate the assessment and UAS information for members in the MLTC and MAP lines of business. - Develop a working relationship with the PCP to be able to contact and discuss the care of the member with them. - Review assessment findings with the PCP to identify any concerns that have not been identified by the clinical team. - Identify the risk factors and assign the risk category to the member. - As part of Care Management team, develops a formal care plan for all services needed for the member, including the member's disaster plan. - Monitor the condition of all members at least monthly, typically by telephone but via face-to-face when necessary. - Identify clinical issues that require immediate clinical assessment and/or treatment to reduce risk of unnecessary hospitalizations, ED visits or nursing home admissions. - Identify opportunities to improve the quality of care by ensuring members receive needed preventative and chronic disease care. - Prior approve request for additional services based on assessments and using evidence based standards refer denial, reduction, or limitation of service request to Medical Director. - Assist members with the coordination of services both within and outside networks as appropriate. Includes facilitating discharge from acute setting and alternate settings. - Provides Care Coordination through continuum of care. Pride Health offers eligible employees comprehensive healthcare coverage (medical, dental, and vision plans), supplemental coverage (accident insurance, critical illness insurance and hospital indemnity), a 401(k)-retirement savings, life & disability insurance, an employee assistance program, identity theft protection, legal support, auto and home insurance, pet insurance, and employee discounts with some preferred vendors.