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Affinity Health Plan

Utilization Management Nurse

3+ months agoThe Bronx, NY


The Utilization Management Nurse will conduct reviews of current inpatient services, and determine medical
appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination in accordance with Utilization Management policies and procedures.


  • Perform utilization management, utilization review, or concurrent review (on-site at a hospital, or telephonic inpatient care management) of hospitalized members ensuring medical necessity, appropriateness of admission, and continued stay following evaluation of medical and benefit determination guidelines. Maintains compliance with all state mandated regulations.
  • Collaboration with hospital staff, physicians, care/service coordinators, plan Medical Director, members and their families to provide the level of care necessary to meet member's health needs.
  • Maintain an active role in assuring the continuity of care for all inpatients through early discharge planning and working with hospital discharge planners and health plan social workers or other staff in the early identification of potential home care candidates or less restrictive level of care placement.
  • Identification and management of members at high risk for readmission or with complex medical and psychosocial needs. Collaboration with Case Manager to coordinate post discharge care and services aimed at:
  • increasing rates of timely outpatient follow-up,
  • ensuring provider treatment plan, medications & outpatient services are in place,
  • safe transition to outpatient setting,
  • improving self management skills,
  • addressing members psychosocial and non-medical needs
  • Communicate directly with physician providers/designees when appropriate to gather all clinical information to determine the medical necessity of requested healthcare services.
  • Maintains courteous, professional attitude when working with Affinity staff, hospital and physician providers, and members.
  • Collect pertinent clinical information and documents all UM review information using the appropriate software system.
  • Manage medical / benefits resources effectively and efficiently while ensuring quality care is provided as determined by guidelines of meeting Medical necessity.
  • Communicate directly with appropriate internal staff regarding all inpatient cases and outpatient/ambulatory requests for health care services that do not meet medical necessity or appropriate level of care and out of network transfer issues.
  • Manage assigned workload within established performance standards.
  • Follow relevant client time frame standards for conducting and communicating UM review determination.
  • Maintain and submit reports and logs on review activities as outlined by the UM program operational procedures.
  • Contribute to MM program goals and objectives in containing health care costs and maintaining a high quality medical delivery system through the program procedures for conducting UM activities.
  • Participate in a multi-disciplinary team approach to address member needs from the acute care phase through the post-acute care phase.
  • Identify and coordinate quality of care issues or trends with the Quality Management department.
  • Demonstrate proficiency with the principles and methodologies of process improvement. Apply these in the execution of responsibilities in support of a process focused approach.
  • Perform other duties as necessary or assigned.

    • Registered Nurse or Licensed Practical Nurse with current, unrestricted, licensure required for state of New York Associates degree in Nursing required; BSN preferred
    • 3+ years Clinical experience and 2 or more years experience working in utilization management required
    • Experience working in Medicaid and/or Medicare managed care, including regulatory and compliance requirements strongly preferred
    • Experience with MCG guidelines preferred
    • Proficiency in software applications that include, but are not limited to, Microsoft Word, Microsoft Excel, Microsoft PowerPoint and Outlook required
    • Ability to work with minimal guidance; seeks guidance on only the most complex tasks
    • Problem solving skills; the ability to systematically analyze problems, draw relevant conclusions and devise appropriate courses of action
    • Excellent verbal and written communication skills; ability to speak clearly and concisely, conveying complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others.
    • Advanced interpersonal (e.g., mediating, counseling, mentoring, influencing), negotiating and management skills required to manage critical internal and external relationships and activities that are diverse and complex. Ability to collaborate constructively with others within and outside the organization.
    • Ability to work resourcefully and creatively, to think independently, and to exercise sound judgment in a complex and dynamic environment.
    • Commitment to the corporate mission, vision, and values.
    • High level of integrity as demonstrated by a) appropriate treatment of confidential information, b) adherence to policies, procedures, rules and regulations, c) professional conduct in dealing with persons internal and external to the organization, and d) sensitivity to the populations served by Affinity and the providers with which Affinity works.

    Client-provided location(s): Bronx, NY, USA
    Job ID: Affinity-1181
    Employment Type: Other