Job description

Want to be a part of an amazing organization? An organization that makes a difference in the lives of individuals each and every day?

Monroe Plan for Medical Care is a not-for-profit health care services organization that has been meeting the needs of low-income and government-sponsored populations in the Greater Buffalo, Rochester, Syracuse, and Binghamton Regions for nearly 50 years. The parent company of MP Care Solutions, Monroe Plan provides Health Home Care Management Services and other health care services to individuals enrolled in Medicaid Managed Care, Child Health Plus and the Essential Plan, including Medicaid-eligible children and families.

Following our mission and vision to improve the health status of individuals and families, Monroe Plan's innovative clinical care management programs are structured to meet the unique needs of members, providers, health care organizations and the communities we serve. Monroe Plan has consistently been recognized as a national leader in the "safety net" area, with a proven track record of improving health outcomes and reducing disparities by supporting a health care delivery system that ensures the availability of high quality medical care for all.

We are currently looking for an experienced and qualified, part time RN for Utilization Management. We offer competitive pay, flexible schedules and great benefits. If you are passionate about helping individuals and working one on one with them, this might be the right fit for you. Our mission encompasses compassion, empowerment and teamwork. We believe if we are supportive and compassionate to our employees, it will spill over to our members.

This is a full time position. Position is remote, Monday - Friday.

GRADE: 307

POSITION SUMMARY
Facilitates the effective utilization of health care resources to optimize member health care outcomes. Enhance access to care and service while maintaining maximum quality and service value. Reviews requests for referrals, prior authorizations and claims adjustments to determine whether health care services that have been provided, are being provided, or are proposed to be provided to a member are medically necessary or experimental /investigational.

POSITION HAS DIRECT REPORTS: No

ESSENTIAL JOB DUTIES/FUNCTIONS

% of Time

Essential Function

75

Utilization Review Functions

• Perform utilization review activities including prospective, concurrent and retrospective reviews.
• Review pended claims for clinical appropriateness of services.
• Make recommendations for approval or denial of services within established time frames.
• Maintain appropriate documentation and records of activities.

15

Work in collaboration with others to gather information relating to all service requests in a timely manner.

10

Identification

• Identify members who could benefit from case management, social work and/or outreach services to optimize health care outcomes and refer to appropriate staff.

OTHER FUNCTIONS AND RESPONSIBILITIES

• Serve as a resource to Monroe Plan staff regarding service utilization.
• Participate in program development and modification in conjunction with appropriate Monroe Plan staff based on utilization program performance and clinical best practices.
• Attend and participate in in-service training/meetings.
• Foster a positive working relationship with providers and Monroe Plan staff.
• Support team member cross coverage as work load dictates.
• Demonstrate flexibility in assuming other job responsibilities as program and organization needs change.
• Adhere to Monroe Plan professional boundaries and protocols.
• Ensure compliance with appropriate confidentiality and other required regulations.Perform other duties as assigned.
• Performs other duties as assigned.

Position Limitations:

• Cannot perform any tasks which are outside scope of practice.
• Cannot transport active Monroe Plan members at any time.
• Cannot make any modifications or suggestions RE: treatment or medication regimen to members.
• Cannot perform hands-on care.

MINIMUM REQUIREMENTS/LICENSES/CERTIFICATIONS
Medical

• Must possess a current NYS RN license.
• Minimum of 2 years in general medicine/surgery/home care required.

Behavioral Health

• Must possess either a current LCSW or a current NYS RN license.
• Minimum of 3 years experience in the Behavioral health field required.
• Excellent communication skills; both oral and written as well as strong interpersonal skills.
• Demonstrated understanding of utilization management, treatment and discharge planning.
• Ability to work independently.
• Strong organizational skills.
• Strong computer and typing skills.

PREFERRED QUALIFICATIONS

• BSN preferred for both positions.
• Prior Utilization Management experience a plus.

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