Utilization Reviewer RN - Monroe Plan for Medical Care : Job Details

Looking for meaningful work with an Organization that values you? It's here!Join our team of dedicated, caring professionals in our passionate pursuit of improved access and quality of healthcare for underserved populations.For over 50 years, Monroe Plan for Medical Care, a not-for-profit health care services organization, has been focused on improving the health status of individuals and families who are recipients of government sponsored health insurance. Monroe Plan is the largest Care Management Agencies serving 28 counties and over 3000 members with an outstanding reputation for excellence throughout our service area!We've earned that reputation by providing quality care management focused on compassion, empowerment, and teamwork. Our award-winning work culture is built on these same principles! When you join our team, you can expect to reap the intrinsic rewards of serving others while enjoying flexible work arrangements, competitive pay, superior benefits, and a supportive, inclusive culture!We are currently looking for an experienced and qualified, part time RN for Utilization Management. We offer competitive pay, flexible schedules and great benefits. If you are passionate about helping individuals and working one on one with them, this might be the right fit for you. Our mission encompasses compassion, empowerment and teamwork. We believe if we are supportive and compassionate to our employees, it will spill over to our members.Position is Full-time remote, Monday - Friday.GRADE: 307The minimum and maximum annual salary that Monroe Plan believes in good faith to be accurate for this position at the time of this posting are $60,949-$78,362. In addition to your salary, Monroe Plan offers a comprehensive benefits package (all benefits are subject to eligibility requirements) and non-monetary perks. The company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws.POSITION SUMMARYFacilitates the effective utilization of health care resources to optimize member health care outcomes. Enhance access to care and service while maintaining maximum quality and service value. Reviews requests for referrals, prior authorizations and claims adjustments to determine whether health care services that have been provided, are being provided, or are proposed to be provided to a member are medically necessary or experimental /investigational.POSITION HAS DIRECT REPORTS: NoESSENTIAL JOB DUTIES/FUNCTIONS % of Time Essential Function75 Utilization Review FunctionsPerform utilization review activities including prospective, concurrent and retrospective reviews\Make recommendations for approval or denial of services within established time frames.Meets or exceeds productivity and quality standards.Maintain appropriate documentation and records of activities.Work in collaboration with others to gather information relating to all service requests in a timely manner.Identify members who would benefit from case management, social work, and/or outreach services to optimize health care outcomes and refer to appropriate staff. 15Work in collaboration with others to gather information relating to all service requests in a timely manner. 10 IdentificationIdentify members who could benefit from case management, social work and/or outreach services to optimize health care outcomes and refer to appropriate staff.OTHER FUNCTIONS AND RESPONSIBILITIES- Serve as a resource to Monroe Plan staff regarding service utilization.- Participate in program development and modification in conjunction with appropriate Monroe Plan staff based on utilization program performance and clinical best practices.- Attend and participate in in-service training/meetings.- Foster a positive working relationship with providers and Monroe Plan staff.- Support team member cross coverage as work load dictates.- Demonstrate flexibility in assuming other job responsibilities as program and organization needs change.- Adhere to Monroe Plan professional boundaries and protocols.- Ensure compliance with appropriate confidentiality and other required regulations.Perform other duties as assigned.- Performs other duties as assigned. Position Limitations: - Cannot perform any tasks which are outside scope of practice.- Cannot transport active Monroe Plan members at any time.- Cannot make any modifications or suggestions RE: treatment or medication regimen to members.- Cannot perform hands-on care.MINIMUM REQUIREMENTS/LICENSES/CERTIFICATIONSMedical-A current NY State RN license-Minium of two years in general medicine/surgery/home care required.-Excellent communication skills; both oral and written as well as strong interpersonal skills.-Demonstrated understanding of utilization management, treatment and discharge planning.-Ability to work independently.-Strong organizational skills.-Strong computer and typing skillsPREFERRED: -Prior Utilization Review or Case Management preferred.