Coordinates the continuum of medical care services for patients to ensure optimum utilization of resources, delivery of quality patient care, and compliance with regulatory, accrediting and contractual requirements. Determines the appropriateness of patient care services, prepares clinical appeals for third party denials, and collects and interprets data for utilization, compliance, QI and other areas as assigned.
Requirements:
- BSN or a bachelor’s degree in a related field required, Master’s preferred
- NYS RN License required
- PRI assessor number required prior to end of 3-month probationary period
- 3-5 years recent acute care clinical experience preferred
- Experience in utilization management preferred
- Experience in a managed care organization preferred
- Certification in Utilization Review or Case Management preferred
- Analytical skills, problem-solving skills, conflict resolution and negotiation skills
- Demonstrated knowledge of federal, state and commercial/third-party regulations related to utilization management functions, discharge planning and associated processes
- Demonstrated knowledge of quality/performance improvement tools and techniques
- Demonstrated knowledge of utilization and case management principles
- Experience in the application of utilization management decision support criteria preferred
- Computer skills including data entry, word processing, and electronic messaging.
- Experience in the use of Windows-based software applications.
- Experience in the use of an electronic clinical information system preferred
- Excellent verbal, written and interpersonal communication skills, as well as a commitment to interdisciplinary teamwork
- Excellent organization skills, teamwork skills and time management skills
- Expert clinical knowledge of disease processes to identify care needs
- Understanding of the health care delivery system and its sites of care, delivery models, and the roles of various providers and health care professionals
- Experience in interpreting and applying benefit coverage rules and assessing coordination of benefits guidelines and managed care regulations required
Department: Care Management Bargaining Unit: 1199 RN Campus: WAKEFIELD Employment Status: Regular Full-Time Address: 600 East 233rd Street, BronxShift: Day Scheduled Hours: 9 AM-5 PM Req ID: 216573 Salary Range/Pay Rate: $57.65
For positions that have only a rate listed, the displayed rate is the hiring rate but could be subject to change based on shift differential, experience, education or other relevant factors.
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Diversity, equity and inclusion are core values of Montefiore. We are committed to recruiting and creating an environment in which associates feel empowered to thrive and be their authentic selves through our inclusive culture. We welcome your interest and invite you to join us.
Montefiore is an equal employment opportunity employer. Montefiore will recruit, hire, train, transfer, promote, layoff and discharge associates in all job classifications without regard to their race, color, religion, creed, national origin, alienage or citizenship status, age, gender, actual or presumed disability, history of disability, sexual orientation, gender identity, gender expression, genetic predisposition or carrier status, pregnancy, military status, marital status, or partnership status, or any other characteristic protected by law.
Mission:
To heal, to teach, to discover and to advance the health of the communities we serve.
Vision:
To be a premier academic medical center that transforms health and enriches lives.
Values
Define our philosophy of care, they shape our actions and motivate and inspire us to pursue excellence and achieve the goals we have set forth for the future. Our values include:
- Humanity
- Innovation
- Teamwork
- Diversity
- Equity