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.