Um Registered Nurse

UM Registered Nurse Overview

• The UM Registered Nurse oversees medical service requests, ensuring compliance with policies and regulations.
• This hybrid role combines remote work and occasional office presence for flexibility.
• Collaborate with care managers and providers to ensure optimal patient care delivery.
• Utilize evidence-based criteria to make informed clinical determinations.
• Provide timely notifications detailing clinical decisions and outcomes.
• Participate in utilization management reviews and appeal processes.
• Support quality improvement initiatives to enhance healthcare services.
• Gather and summarize data for reporting and documentation purposes.
• Ensure compliance with state and federal regulations in all activities.

UM Registered Nurse Key Responsibilities & Duties

• Review healthcare services to ensure medical necessity and effectiveness.
• Match member care needs to available resources and adjust as needed.
• Consult with Medical Director for complex service reviews.
• Maintain accurate and complete case documentation and correspondence.
• Conduct utilization reviews, including prospective, concurrent, and retrospective evaluations.
• Participate in appeals processes to address service decisions.
• Support quality and performance improvement initiatives within the organization.
• Summarize data for reporting purposes and contribute to organizational goals.
• Ensure adherence to all applicable policies, procedures, and regulations.

UM Registered Nurse Job Requirements

• Valid New York State RN license without restrictions.
• Associate degree in nursing or related field; BSN preferred.
• Minimum of 1 year of experience in a similar role.
• Medicare experience is required for this position.
• Strong knowledge of utilization management processes and evidence-based criteria.
• Proficiency in documentation and data summarization for reporting purposes.
• Ability to consult and collaborate with medical professionals effectively.
• Commitment to quality improvement and regulatory compliance.
• Excellent organizational and communication skills.