Job Description

Job Title: Utilization Management / Appeals Registered Nurse

Job Details

• Posting Date: 4/16/2025
• Reference ID: 210559
• Locations: New Hyde Park, NY
• Work Location: Onsite
• Discipline: Nursing / Utilization Management
• Job Type: Contract to hire
• Salary Expectations: $50 - $54/hour
• Schedule/Shift: Monday to Friday, 8:00 AM – 5:00 PM

Job Description

Responsibilities/Job Duties:

• Conduct reviews for State and Federal Independent Dispute Resolution (IDR) case determinations, including prior authorizations and disputed benefit reviews.
• Review medical charts, compile regulatory guidance, research insurer requirements, and complete electronic worksheets.
• Prepare final determinations for disputed claims and appeals.
• Act as a resource for administrative and clinical staff by offering training, technical assistance, and conducting staff huddles.
• Mentor and train new RNs as the project expands.
• Assess and adjudicate claims, ensuring accuracy and compliance with regulations.
• Participate in collaborative training sessions and staff meetings.
• Handle a mix of simple and complex cases, reviewing documentation and coding for out-of-network bills to determine next steps.

Minimum Education and Experience Qualification Requirements:

Education:

• Baccalaureate degree in Nursing (BSN) required.
• Graduate of an approved Registered Professional Nursing program.
• New York State Registered Nurse License

Experience:

• Minimum of 2 years in a clinical setting.
• Knowledge of Utilization Management, Appeals, or Clinical Documentation PREFERRED
• Familiarity with electronic medical records (EMR) systems.

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