VillageCare
Utilization Review Nurse
VillageCare
is looking for a self‑motivated and passionate RN for a full‑time, remote utilization review role. The position is based in the New York Tri‑State Area (NY, NJ, CT) and requires an unrestricted NYS RN license.
Responsibilities
Review planned, in process, or completed health care services to ensure medical necessity and effectiveness according to evidence‑based criteria (prospective, concurrent, and retrospective review).
Collaborate and communicate with physician peer reviewers and medical directors to determine coverage of requested services.
Provide intervention and coordination to decrease delays and denials.
Maintain timely, complete, and accurate documentation in compliance with VCMAX policies and procedures.
Support Quality and Performance Improvement Initiatives.
Follow up on results of denial and internal appeal reviews.
Qualifications
Current unrestricted NYS RN license; URAC preferred.
BSN (advanced degree preferred); minimum 2+ years of utilization review experience within a Managed Care Organization or Health Plan.
Inpatient experience required; experience with MLTC and Hospital/SNF required.
Working knowledge of Medicaid and/or Medicare regulations as well as coverage guidelines and benefit limitations.
Ability to apply InterQual/ Milliman Care Guidelines and other evidence‑based clinical guidelines.
Must reside in the New York Tri‑State Area (NY, NJ, CT).
Benefits
PTO package, 10 paid holidays, personal and sick time
Medical/Dental/Vision, HRA/FSA, education reimbursement
Retirement savings 403(b), life & disability, commuter benefits, paid family leave, employee discounts
Salary: $95,000 – $105,000 per year.
VillageCare is an Equal Opportunity Employer.
#J-18808-Ljbffr
is looking for a self‑motivated and passionate RN for a full‑time, remote utilization review role. The position is based in the New York Tri‑State Area (NY, NJ, CT) and requires an unrestricted NYS RN license.
Responsibilities
Review planned, in process, or completed health care services to ensure medical necessity and effectiveness according to evidence‑based criteria (prospective, concurrent, and retrospective review).
Collaborate and communicate with physician peer reviewers and medical directors to determine coverage of requested services.
Provide intervention and coordination to decrease delays and denials.
Maintain timely, complete, and accurate documentation in compliance with VCMAX policies and procedures.
Support Quality and Performance Improvement Initiatives.
Follow up on results of denial and internal appeal reviews.
Qualifications
Current unrestricted NYS RN license; URAC preferred.
BSN (advanced degree preferred); minimum 2+ years of utilization review experience within a Managed Care Organization or Health Plan.
Inpatient experience required; experience with MLTC and Hospital/SNF required.
Working knowledge of Medicaid and/or Medicare regulations as well as coverage guidelines and benefit limitations.
Ability to apply InterQual/ Milliman Care Guidelines and other evidence‑based clinical guidelines.
Must reside in the New York Tri‑State Area (NY, NJ, CT).
Benefits
PTO package, 10 paid holidays, personal and sick time
Medical/Dental/Vision, HRA/FSA, education reimbursement
Retirement savings 403(b), life & disability, commuter benefits, paid family leave, employee discounts
Salary: $95,000 – $105,000 per year.
VillageCare is an Equal Opportunity Employer.
#J-18808-Ljbffr