Utilization Review Nurse

Company: Capital District Physicians Health Plan Inc
Location: Albany
Posted on: April 4, 2025

Job Description:

Grounded by a compelling mission, core values, and compassion for people, CDPHP and its family of companies offer a strong foundation for a rewarding career. Established in 1984, CDPHP is a physician-founded, member-focused, and community-based not-for-profit health plan that offers high-quality affordable health insurance to members throughout New York. The company values people, quality, innovation, and community, and its corporate culture supports those values wholeheartedly. CDPHP is committed to fostering a culture of belonging and takes a wholistic approach to diversity, equity, and inclusion. At CDPHP, the employees have a voice and are encouraged to make an impact at both the company and community levels through engagement and volunteer opportunities. CDPHP invests in employees who share these values and invites you to be a part of that experience.

The Utilization Review (UR) Nurse is responsible for the clinical review and documentation for services requiring prior authorization. This includes approval determinations and appropriate exceptions, coordinating with Medical Directors on denials. In addition, the UR nurse is responsible for completing inpatient level of care reviews, post-acute care initial and concurrent reviews for acute and subacute rehabilitation, transportation, DME requests and inpatient readmissions. In collaboration with management, the UR nurse identifies potentially high-cost admissions and extended stays. The UR Nurse is also responsible for providing education to both internal and external constituents on nationally recognized criteria and CDPHP policies, and procedures.

QUALIFICATIONS:

• Registered Nurse with a current New York State license required.
• Associates degree required.
• Minimum two (2) years of acute care experience is required as a Registered Nurse.
• Minimum of two (2) years Utilization Management experience is preferred.
• Knowledge of coding/claims processing is preferred.
• Experience working with Microsoft Office, including Outlook, Word and Excel, and other databases required.
• Demonstrated ability to pro-actively identify problems and recommend solutions.
• Demonstrated ability to stay organized and work effectively within strict deadlines.
• Demonstrated ability to build relationships, internally and externally, including providers, members and community agencies to positively impact the quality of patient care.
• Demonstrated ability to provide excellent customer service.
• Demonstrated ability to review health care delivery against established criteria.
• Must be available after business hours for on-call rotations as needed.
  CDPHP salary ranges are designed to be competitive with room for professional and financial growth. Individual compensation is based on several factors unique to each candidate, such as work experience, qualifications, and skills. In addition to cash compensation, CDPHP employees may be eligible for an incentive payment, a discretionary cash reward based on employee and company performance. Some roles may also be eligible for overtime pay.
  
  CDPHP compensation packages go far beyond just salary. The company offers a comprehensive total rewards package that includes award-winning health care coverage, health care dollars, a generous paid time off allowance, employee assistance programs, flexible work environment, and much more. Learn about all CDPHP employee benefits at https://www.cdphp.com/about-us/jobs/benefits.
  
  As an Equal Opportunity / Affirmative Action Employer, CDPHP will not discriminate in its employment practices on the basis of race, color, creed, religion, sex (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity or expression, transgender status, age, national origin, marital status, citizenship, disability, criminal record, genetic information, predisposition or carrier status, status with respect to receiving public assistance, domestic violence victim status, protected veterans status, or any other characteristics protected under applicable law. To that end, all qualified applicants will receive consideration for employment without regard to any such protected status.
  
  CDPHP and its family of companies include subsidiaries Strategic Solutions Management Consultants (SSMC), Practice Support Services (PSS), and ConnectRx Services, LLC.

Keywords: Capital District Physicians Health Plan Inc, Albany , Utilization Review Nurse, Healthcare , Albany, New York