Registered Nurse, Utilization Review

About Nascentia Health

Nascentia Health is leading the way in home care, post acute care and long-term community health. A healthcare system without walls, Nascentia is an innovator in the concept of healthcare, truly focused on the patient as a whole. By serving people in their homes, Nascentia Health is able to provide true holistic care. We can address immediate needs, help support positive long term medical and lifestyle choices that provide for better outcomes, leverage cutting edge in-home care technologies, and help avoid unnecessary visits to busy healthcare facilities.

Nascentia Health is an Equal Opportunity Employer (EOE)

Job Qualifications

• Current NYS RN licensure, BSN preferred
• Five or more years of home health care or long term care experience strongly preferred
• Three or more years of utilization management or quality improvement experience preferred

Professional Competencies, Skills and Abilities

• Excellent relationship management skills
• Demonstrated ability to problem solve complex, multifaceted situations
• Successfully manage conflict and negotiate a win win solution
• Strong organizational, prioritizing and delegation skills
• Abstract thinking
• Strong communication skills written and verbal
• Advocacy focused
• Ability to be non-judgmental
• Computer literacy with Microsoft office products

Physical Requirements

• Speech, visual, and hearing ability sufficient to express and comprehend written and verbal communication
• Ability to sit 90% of the day
• Frequent sitting, standing, walking
• Pushing, pulling, reaching, kneeling
• Bloodborne Pathogens Exposure Determination Category: Category III

Performance Responsibilities and Standards

• Aid in the review of member usage patterns for medical necessity and appropriateness
• Perform continuing review of medical records and supporting documentation for medical necessity where appropriate
• Track and analyze service utilization patterns monthly and compare to regional benchmarks
• Review appeals and provide notice of determination
• Receive and respond to Office of Temporary and Disability Assistance (OTDA) notifications of Fair Hearings
• Prepare for and attend Fair Hearings
• Aid in the development of coverage policy guidelines for MLTC services
• Participate in interdisciplinary collaboration with professional staff
• Create and facilitate educational programs
• Identify and collaborate with UR Manager on individual cases
• Identify and collaborate with UR Manager on trends in usage patterns
• Process Notice of Action letters
• Perform concurrent, prior service authorizations and retrospective reviews
• Analyze per member per month (PMPM) data
• Other duties as assigned

Compensation & Benefits

• Competitive Salary [This position is an S03 exempt position with a min-max rate of: $72,415-$83,922/annually]
• 401K with generous Employer match
• Medical, Dental, Vision plans
• Tuition Reimbursement for BSN after 6 months of employment
• Exceptional work/life balance - no rotating shifts
• Partially funded HSA
• Employee Recognition Platform
• Paid Time Off, Holidays, and Extended Sick Leave
• Short/Long term Disability
• Employee Assistance Program (EAP)
• Many more!