Summary of Position
- Perform clinical reviews within the Medical Management Operations Concurrent Review utilization management department.
- Ensure accurate administration of benefits, execution of clinical policy and timely access to appropriate levels of care.
Principal Accountabilities
- Under the direction of the leader, is responsible for the execution of efficient departmental processes designed to manage inpatient utilization within the benefit plan.
- Act as the clinical coordinator collaborating with members and facilities to evaluate member needs within the inpatient setting.
- Establish and maintain active working relationships with assigned facility care managers/utilization management departments to facilitate appropriate clinical reviews and patient care.
- Enter and maintain documentation in the TPH platform meeting defined timeframes and performance standards.
- Communicate authorization decisions and important benefit information to providers and members in accordance with applicable federal and state regulations, and NCQA and business standards.
- Review and investigate member and provider requests to determine appropriate utilization of benefits and/or claim adjudication.
- Research evidence-based guidelines, medical protocols, provider networks, and on-line resources in making coverage determinations and recommendations.
- Prepare and present clinical case summaries in routine inpatient rounds.
- Maintain an understanding of utilization management, program objectives and design, implementation, management, monitoring, and reporting.
- Identify quality, cost and efficiency trends and provide solution recommendations to Supervisor/Manager.
- Actively participate on assigned committees.
- Perform other related projects and duties as assigned.
Qualifications Education, Training, Licenses, Certifications
- Associate's degree or bachelor's degree in nursing.
- Valid RN License without restriction.
- May require a CME accreditation in specific specialties.
- Certification in utilization or care management preferred
Relevant Work Experience, Knowledge, Skills, and Abilities
- 4 - 6+ years of Nursing experience.
- Case and/or utilization management/care coordination and managed care experience.
- Strong communication skills (verbal, written, presentation, interpersonal) with all types/levels of audience.
- Organizing and prioritizing skills, and strong attention to detail.
- Trained in the use of Motivational Interviewing techniques.
- Experience working in physician practice and/or with electronic medical records.
- Proficient with MS Office (Word, Excel, PowerPoint, Outlook, Teams, SharePoint, etc.).
- Proficiency with the use of mobile technology (Smartphone, wireless laptop, etc.).
Additional Information
- Requisition ID: 1000002996
- Hiring Range: $68,040-$118,800
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EmblemHealth
May 02, 2026