Remote Nurse Care Manager - Utilization Management | WFH

Remote Utilization Management Nurse Care Manager

Join our esteemed team as a Remote Utilization Management Nurse Care Manager and contribute to the delivery of superior patient care. In this pivotal role, you will manage both straightforward and intricate medical cases, ensuring optimal patient outcomes while effectively reducing unnecessary healthcare expenses.

Key Responsibilities

• Execute care management functions, including hospital admission certification, continued stay evaluations, discharge planning, and reviews of outpatient and ancillary services, adhering to established Utilization Management policies and protocols.
• Supervise the coordination and delivery of comprehensive healthcare services to members requiring care management, emphasizing cost-effective solutions.
• Collaborate with members’ primary care providers (PCPs) and other healthcare professionals to gather essential clinical information; approve care that meets established criteria and refer other cases to the Physician Advisor or Medical Director.
• Communicate Utilization Management determinations and treatment alternatives to both members and providers.
• Identify utilization patterns and potential member needs through generating reports derived from encounter data, pharmacy data reviews, and health assessment forms for new members.
• Assess member requirements for referred cases, whether initiated by providers or through self-referrals by members.
• Assist various departments in addressing members’ concerns related to utilization management issues.
• Ensure compliance with all regulatory agency requirements throughout all Utilization Management activities.
• Conduct medical record reviews as appropriate to your case management responsibilities.
• Participate in Medical Management grand rounds with the Physician Advisor.
  
  

Qualifications

• A minimum of 2 to 5 years of clinical experience in an acute or applicable care setting.
• Significant experience in Utilization Management or Utilization Review within a managed care or hospital environment is essential.
• Proven experience handling Appeals and Grievances or Personal Care Services (PCS) Utilization is required.
• Must possess a valid New York State nursing license as a Registered Nurse (RN) or Licensed Practical Nurse (LPN).
  
  

Career Growth Opportunities

This role offers significant potential for professional development within our clinical services team. You will have the opportunity to work alongside experienced professionals, participating in discussions that enhance your knowledge and skills.

Compensation And Benefits

• Full-time, permanent employment.
• Competitive salary with the potential to earn up to $105,500+ annually.
• Comprehensive benefits package, including a pension plan.
• Fully remote working environment, with the exception of a one-day onboarding at our NYC office.
  
  

We are committed to fostering a collaborative and supportive environment where patient care remains a top priority. Join us in making a meaningful impact on patient outcomes and experience the professional growth that comes with being part of our reputable organization.

Employment Type: Full-Time