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Staff - Registered Nurse RN - Clinic Utilization Review - 93K - K Per Year
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- VNS Health is seeking a Registered Nurse (RN) Clinic Utilization Review for a nursing job in Manhattan, New York. Job Description & Requirements Specialty: Utilization Review Discipline: RN Start Date: ASAP Duration: Ongoing Employment Type: Staff Resolves grievances, appeals and external reviews for one of the following VNS Health Plans product lines – Managed Long Term Care (MLTC), Medicare Advantage (MA), or Select Health.
- Creates and maintains accurate records documenting the actions and rationale for each grievance or appeal decision.
- Conducts review of requests for prior authorization of health services, as required in certain product lines, and prepares written responses consistent with regulatory requirements.
- External reviewers include New York State (Fair Hearings), Centers for Medicare and Medicaid Services (CMS), Independent Review Entities and Quality Improvement Organizations.
- Collaborates with professionals, health plan departments such as Claims and Medical Management, and the third party administrator staff and legal, as necessary, to investigate and facilitate resolution of individual grievances and appeals.
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