Responsibilities:
• Use industry criteria, SPD benefit plan design, clinical knowledge, and critical thinking to assess, plan and provide, ongoing coordination and management of service delivery through an integrated case management approach
• Performs medical necessity review that includes Fund and Vendor concurrent, prospective, retrospective reviews and 1st level appeals, to ensure compliance with applicable criteria, medical policy, member eligibility, benefits and vendor contracts
• Assist in preparing cases where no prior authorization obtained, 1st level, 2nd level and Urgent appeal, create clinical summaries and present to Assistant Director/Director
• Prepare cases for submission to external Independent Review organizations and present to Assistant Director/Director
• Apply Milliman Care Guidelines, eviCore and CareAllies/Cigna (Vendor) Clinical Guidelines, internal Fund Policies and Reference Guides to determine medical necessity for clinical services and those requiring Prior Authorization
• Summarize and analyze highly complex clinical cases including but not limited to clinical trials, CAR-T therapy, genomic testing, Inhaled Nitric Oxide, Implants and experimental/unproven treatments
• Maintain accurate records of all patient/provider/vendor related interactions in document medical management system (DMS)
• Apply clinical guidelines, provide recommendations and discuss cases with Medical Consultants
• Meet timeliness and quality standards related to Utilization Management
• Maintain and submit reports and logs on reviewed activities as outlined by the UM program operational procedures
• Authorize vendor services using clinically proven criteria to make consistent care decisions
• Identify and problem solve issues with appropriate services to ensure positive member outcomes utilizing cost efficient covered services
• Responsible for abiding by and supporting the care management programs to ensure quality and efficient clinical operations
• Perform additional duties and projects as assigned by management

Qualifications:
• Association or Bachelor's degree required. Valid New York State Registered (RN or LPN) required
• Minimum three (3) years Medical/Surgical experience plus a minimum of two (2) years Utilization Management experience required
• Certification in Case Management a plus
• Proficient in application and use of industry standard Utilization Management criteria (Milliman Care Guidelines), Medicare and coverage guidelines, health claims processing, medical coding
• Excellent verbal and written communication skills, problem-solving, clinical assessment, care planning skills, and independent decision-making capability
• Computer and organizational skills required, ability to manage competing priorities, multi-task with results-oriented outcomes and work in a fast paced environment. Intermediate skills of Microsoft Office systems preferred