Utilization Review Manager-Selikoff Centers for Occupational Health

The Utilization Review Manager for the Selikoff Centers for Occupational Health is responsible for the management of program operations within a particular department/unit. This includes, but is not limited to, the management of: 

• Program-specific applications, quality improvement, staff education, medical records, and internal and external regulatory and survey requirements.  
• The Utilization Review Manager collaborates with multiple professionals to support and coordinate the provision/management of patient benefits.
• Works closely with the Nursing Clinical Director, Physician Leader, and staff to ensure that assigned department/unit maintains the highest standards of patient care and is responsive to the needs of the patient & family as well as the organization. 
• The Utilization Review Manager will be required to maintain an up-to-date, in-depth knowledge of health program coverage guidelines as well as other relevant standards in making coverage decisions.
• This position will involve establishing a connection between the standard of care and how it relates to program coverage. 

• Develops, implements, and maintains professional and hospital standards to support outcomes-based care and evidence-based nursing practice.
• Works closely with assigned unit, Nursing Department, and other hospital departments to ensure that the highest expectations of all regulatory and professional standards are met.
• Supports the overall strategic goals and service standards of the Hospital and the Nursing Department.
• Performs utilization review in accordance with all regulations, using health plan management tool based on program guidelines and best practices; routes requests to medical leadership when appropriate
• Documents authorization review for medical and pharmacy claims. 
• Prepares case reports, summaries, or other related documents required to modify and/or add necessary services.
• Performs continuing review of medical records; analyzing data trends and implementing best practices to ensure cost-effective and high quality care delivery.
• Respond to inquiries regarding plan coverage, consult with medical leadership when appropriate.
• Communicates decisions and outcomes to the case management team.
• Provides education on Program guidelines and coverage determination to interdisciplinary teams.
• Makes recommendations on system improvements to streamline clinical review processes, participates in the implementation of such optimizations and takes a leading role in staff retraining, when applicable.
• Supports clinical improvement activities of core business groups by providing quality review. Records and reports all information to clinical leadership.
• Other related duties as assigned by the program medical director, manager, and administrator.

• BSN required; Master in Nursing or health-related field preferred.
• 5 years minimum of progressive acute care leadership and acute care utilization review experience. 
• Demonstrate solid critical thinking and a strong clinical background
• Must have relevant clinical competence in the area of nursing practice assigned; in this case, acute care utilization review. 
• Previous experience making recommendations about what services and treatments are most appropriate, in addition to previous experience working with insurance companies, providers, and their families to ensure coverage for the services provided.
• Current experience with prior authorizations, claims, appeals, discharge planning.
• Licensed as a registered professional nurse with current registration in New York State.
• Basic Life Saver (BCLS) Required   Issuing Agency: AHA

 

 

Strength Through Diversity

The Mount Sinai Health System believes that diversity, equity, and inclusion are key drivers for excellence. We share a common devotion to delivering exceptional patient care. When you join us, you become a part of Mount Sinai’s unrivaled record of achievement, education, and advancement as we revolutionize medicine together. We invite you to participate actively as a part of the Mount Sinai Health System team by:  

• Using a lens of equity in all aspects of patient care delivery, education, and research to promote policies and practices to allow opportunities for all to thrive and reach their potential.
• Serving as a role model confronting racist, sexist, or other inappropriate actions by speaking up, challenging exclusionary organizational practices, and standing side-by-side in support of colleagues who experience discrimination.
• Inspiring and fostering an environment of anti-racist behaviors among and between departments and co-workers.

We work hard to acquire and retain the best people and to create an inclusive, w