Utilization review nurse [h1.location_city]

Acacia Network Utilization Manager

Are you ready to give back to the community while pursuing your passion? For over 50 years, Acacia Network and its affiliates have been committed to improving the quality-of-life and wellbeing of underserved communities in New York City and beyond. We are one of the leading human services organizations in New York City and the largest Hispanic-led nonprofit in the State, serving over 150,000 individuals every year. Our programs serve individuals at every age and developmental level, from the very young through our daycare programs to mature adults through our older adults centers. Our extensive array of community-based services are fully integrated, bilingual and culturally competent.

The Utilization Manager is responsible for the day-to-day functions of collaborative communication with external case managers at referring provider facilities and / or managed care organizations (MCO) for data collection, interpretation, and certification / recertification from third party payers at pre-admission through discharge, ongoing medical necessity reviews and interdisciplinary team support with respect to MCO requisites. In addition, this position is responsible for having a thorough understanding of patient treatment plans through participative discussions with the care plan (interdisciplinary) team, identifying and referring requests for services to the Medical Director when guidelines are not met and reviewing residential services requiring MCO approval.

Key Essential Functions

• Obtaining the required pre-authorization / certification of specified services from the MCO and communicating end of benefit status and / or reimbursement changes to Finance and others as deemed necessary.
• Conducting ongoing medical necessity reviews, which may be pre-service, concurrent and / or retrospective in nature, by evaluating clinical data and submitting appropriate documentation to update the patient / resident's status to the MCO as scheduled.
• Acting as a liaison between the residential program and the MCO to better facilitate the reimbursement process.
• Referring MCO denials and non-covered medical services to the directors for appeal determination and next steps
• Conduct medical record reviews of all managed care patients within the first 24 to 72 hours (if admitted on a Friday after 5 : 00pm) then weekly as required to promote desired clinical and financial outcomes by, but not limited to :
• Meeting with all managed care residents / patients to better assist in the selection of appropriate provider resources and identification of quality and cost-effective services throughout the continuum of care.
• Acting as a resource to the interdisciplinary team regarding MCO requirements for admission, continued stay and discharge planning.
• Providing early identification of covered care and ensuring that claims are approved when the requirements are met.
• Collaborate with clinicians to identify discharge needs and coordinates with Social Services in the creation and implementation of a discharge / transfer plan.
• Coordinates post-discharge follow-up care with selected patients and community providers.
• Maintains strong leadership skills to perform the multiple functions and a wide variety of tasks requiring independent judgment, ingenuity, and initiative.
• Interacts with executives, directors, key members of the residential team, physicians, and their staff, third party payers, state and federal agencies, auditors, and vendors.
• Maintains a high degree of computer proficiency with MS Word and MS Excel which is critical for the analysis conducted using this technology.
• Maintains all information in a manner such as to assure strict confidentiality and compliance with HIPPAA.
• Maintains full knowledge and understanding of state and federal regulations as they pertain to resident assessment requirements.
• Performs all other tasks including miscellaneous special projects as directed.

Requirements

Why Join Us?

Acacia Network provides a comprehensive and competitive benefits package to our employees. In addition to a competitive salary, our benefits include medical, dental, and vision coverage. We also offer generous paid time off, including vacation days and paid holidays, to support a healthy work-life balance. We prioritize the well-being of our employees both professionally and personally.

As an Equal Opportunity Employer, we encourage individuals from all backgrounds to apply.