RN Utilization Management – Case Management (Medicaid Long Term Care) Position Available In Westchester, New York
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Job Description
Job Order Number:
DG0181398
Job Title:
RN Utilization Management – Case Management (Medicaid Long Term Care)
Company:
Elevance Health Location:
Yonkers, NY
Salary:
Education:
Information Not Provided
Experience:
Information Not Provided
Hours:
Duration:
Full Time, Regular
Shift:
Description:
RN Utilization Management – Case Management (Medicaid Long Term Care)
JR155671
- Location
- : New York or New Jersey.
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Virtual:
- This role enables associates to work virtually full-time, with the exception of required in-person training sessions as needed, providing maximum flexibility and autonomy.
This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development as needed.
The
- Medical Management Nurse
- is responsible for review of the most complex or challenging cases that require nursing judgment, critical thinking, and holistic assessment of member’s clinical presentation to determine whether to approve requested service(s) as medically necessary.
Works with healthcare providers to understand and assess a member’s clinical picture. Utilizes nursing judgment to determine whether treatment is medically necessary and provides consultation to Medical Director on cases that are unclear or do not satisfy relevant clinical criteria. Acts as a resource for Clinicians. May work on special projects and helps to craft, implement, and improve organizational policies. Primary duties may include but are not limited to:+ Utilizes nursing judgment and reasoning to analyze members’ clinical information, interface with healthcare providers, make assessments based on clinical presentation, and apply clinical guidelines and/or policies to evaluate medical necessity.+ Works with healthcare providers to promote quality member outcomes, optimize member benefits, and promote effective use of resources.+ Determines and assesses abnormalities by understanding complex clinical concepts/terms and assessing members’ aggregate symptoms and information.+ Assesses member clinical information and recognizes when a member may not be receiving appropriate type, level, or quality of care, e.g., if services are not in line with diagnosis.+ Provide consultation to Medical Director on particularly peculiar or complex cases as the nurse deems appropriate.+ May make recommendations on alternate types, places, or levels of appropriate care by leveraging critical thinking skills and nursing judgment and experience.+ Collaborates with case management nurses on discharge planning, ensuring patient has appropriate equipment, environment, and education needed to be safely discharged.+ Collaborates with and provides nursing consultation to Medical Director and/or Provider on select cases, such as cases the nurse deems particularly complex, concerning, or unclear.+ Serves as a resource to lower-level nurses.+ May participate in intradepartmental teams, cross-functional teams, projects, initiatives and process improvement activities.+ Educates members about plan benefits and physicians and may assist with case management.+ Collaborates with leadership in enhancing training and orientation materials.+ May complete quality audits and assist management with developing associated corrective action plans.+ May assist leadership and other stakeholders on process improvement initiatives.+ May help to train lower-level clinician staff.
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Minimum Requirements:
- + Requires a minimum of associate’s degree in nursing.
+ Requires a minimum of 4 years care management or case management experience and requires a minimum of 2 years clinical, utilization review, or managed care experience; or any combination of education and experience, which would provide an equivalent background.+ Current active, valid and unrestricted RN license and/or certification to practice as a health professional within the scope of licensure in the state of residence required.
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Preferred Skills, Capabilities and Experiences:
- + A combination of utilization review/utilization management and Case Management (or care management) experience in a managed care setting is highly preferred.
+ Experience with, or knowledge of, the Medicaid population is preferred.+ Experience with home health, Long Term Service and Support, spec