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Utilization Management / Appeals Registered Nurse
- Posted: March 19, 2025
- Salary:US$50 - US$54 per hour
- Location:New Hyde Park
- Job type: Contract
- Discipline:Care Management
- Reference:210559_1742404009
- Work Location:On-site
Job description
Job Title: Utilization Management / Appeals Registered Nurse
Job Details
- Posting Date: 3/19/2025
- Reference ID: 240421
- Locations: New Hyde Park, NY
- Work Location: Onsite
- Discipline: Nursing / Utilization Management
- Job Type: Contract to hire
- Salary Expectations: $50 - $54/hour
- Schedule/Shift: Monday to Friday, 8:00 AM - 5:00 PM
Job Description
Responsibilities/Job Duties:
- Conduct reviews for State and Federal Independent Dispute Resolution (IDR) case determinations, including prior authorizations and disputed benefit reviews.
- Review medical charts, compile regulatory guidance, research insurer requirements, and complete electronic worksheets.
- Prepare final determinations for disputed claims and appeals.
- Act as a resource for administrative and clinical staff by offering training, technical assistance, and conducting staff huddles.
- Mentor and train new RNs as the project expands.
- Assess and adjudicate claims, ensuring accuracy and compliance with regulations.
- Participate in collaborative training sessions and staff meetings.
- Handle a mix of simple and complex cases, reviewing documentation and coding for out-of-network bills to determine next steps.
Minimum Education and Experience Qualification Requirements:
Education:
- Baccalaureate degree in Nursing (BSN) required.
- Graduate of an approved Registered Professional Nursing program.
Experience:
- Minimum of 2 years in a clinical setting.
- Knowledge of Utilization Management, Appeals, or Clinical Documentation PREFERRED
- Familiarity with electronic medical records (EMR) systems.
Benefits:
- Paid Sick Leave
- Health Benefits / Dental / Vision
- 401k
- Short Term Disability Insurance
- Term Life Insurance Plan
For California Applicants:
We will consider for employment all qualified Applicants, including those with criminal histories, in a manner consistent with the requirements of applicable federal, state and local laws, including the City of Los Angeles' Fair Chance Initiative for Hiring Ordinance (FCIHO), Los Angeles Fair Chance Ordinance for Employers (ULAC), The San Francisco Fair Chance Ordinance (FCO) , and the California Fair Chance Act (CFCA).
This position is subject to a background check based on its job duties, which may include patient care, working with vulnerable populations, access to financial and confidential information, driving, working with heavy machinery, or working in a warehouse or laboratory environment. Due to these job duties, this position has a significant impact on the business operations and reputation, as well as the safety and well-being of individuals who may be cared for as part of the job position or who may interact with staff or clients.