Remote RN Utilization Management Policy Analyst – New York

Job Overview

  • Clinical License RN
  • State(s) NY

Full job description

RN, Utilization Management Policy Analyst (Remote)

  • Join a wonderful, not for profit healthcare org!
  • Fully remote – 40 hours per week (Monday thru Friday, business hours)
  • Work within a cohesive UM Department
  • Up to $108K plus very strong benefits (ie. 6 weeks’ vacation, 401k match, etc.)

About the position:

The RN UM Program Analyst researches, develops, implements, and revises medical policies and policies pertaining to the Utilization Management Department. Responsibilities include evaluating policy options and making recommendations, soliciting input from various internal and external stakeholders including professional organizations and health care providers and providing training to internal staff. Serves as the primary resource in Utilization Management for URAC reaccreditation and readiness. Oversees auditing of system approved authorizations. Provides support to the UM Clinical Systems Administrator. Performs support to the UM Prior Authorization and Inpatient teams as needed through review of outpatient and inpatient authorization requests.

  • Reviews and evaluates medical policies.
  • Maintains HUSKY provider benefit grids.
  • Evaluates CT state policy changes to determine if benefit grid or medical policy changes are necessary and if so, facilitates those changes.
  • Reports to the Medical Policy Committee on all activities related to medical policies.
  • Assists in leading the Medical Policy Workgroup, which includes setting agendas and meeting schedule to ensure all policies are reviewed in a timely fashion.
  • Has strong working knowledge of ASO contract and URAC HUM standards.
  • Ensures UM policies are compliant with both.
  • Trains internal staff on medical and UM policies.
  • Works closely with UM System Administrator on portal maintenance, updates, and provider training.
  • Reviews auditing reports and identifies provider trends in auditing results of authorization requests submitted via the portal.
  • Provides support to the UM Prior Authorization and Inpatient teams as needed through review of outpatient and inpatient authorization requests.
  • Carries out any other duties as appropriate to the position to support the Director of UM and VP of Clinical Affairs
  • Works closely with the Director of UM and Vice President of Clinical Affairs on policy topics and coordination of Medical Policy Workgroup.
  • Maintains a tracking system for medical and UM policies.
  • Maintains current understanding of contractual requirements, URAC standards, and CT state policy and benefit changes.
  • Performs audits of portal authorization requests.
  • Provides support to prior authorization and inpatient teams performing reviews as needed

What we’re looking for:

  • Registered Nurse with a BSN or master’s degree in nursing
  • 3+ years of experience in UM policies and processes, medical coding and benefits. Informatics and data analytics is preferred but not required.
  • Experience with InterQual
  • Certified Professional Coder (CPC) or Certified Coding Specialist (CCS) preferred
  • Strong understanding of the processes of utilization management
  • Excellent written and verbal communication skills

Job Type: Full-time

Pay: $92,000.00 per year

Benefits:

  • 401(k)
  • 401(k) matching
  • Dental insurance
  • Flexible schedule
  • Flexible spending account
  • Health insurance
  • Life insurance
  • Paid time off
  • Retirement plan
  • Tuition reimbursement
  • Vision insurance

Schedule:

  • 8 hour shift
  • Monday to Friday

Application Question(s):

  • Are you comfortable working remotely? This is a remote position.
  • Do you reside in NY? This is required.

Education:

  • Bachelor’s (Required)

Experience:

  • RN Utilization Management/Prior Auth: 3 years (Required)

License/Certification:

  • RN License (Required)

Work Location: Remote

Thanks for visiting!

The Remote Nurse is a large online community and Job Board specializing in Remote Clinical Jobs for Nurses, Nurse Practitioners, and Physician Assistants.

Follow us!