RN Utilization Management Nurse

Amida Care, the largest Medicaid HIV Special Needs Plan in NY, delivers a uniquely effective care model that has become a true benchmark for innovation, engagement and member health outcomes. Our mission is to provide access to comprehensive care and coordinated services that facilitate positive health outcomes and general well-being for our members. This true integrative care model addresses psychosocial, housing, behavioral and medical services directly evolving around the needs of each member.

We are a community of individuals from diverse peoples who work together to actively foster a fair, equitable, inclusive environment where all employees receive an invitation to belong. Visit www.amidacareny.org for more information about the Amida Care culture.

We are actively seeking a highly motivated, innovative and experienced leader to join our team as the RN Utilization Management Nurse. Compensation will be commensurate with experience.

Position Summary

This position is responsible for completing utilization management (UM) for all gender affirming services (GAS) requests for our Transgender/ Non-Binary members.

Responsibilities

• Coordinate, in conjunction with Clinical Services, Utilization Management (UM) determinations in accordance with Article 49-Utilization Review.
• Ensure UM is completed by following all regulatory guidelines and timeframes.
• Document all UM activities in the appropriate database.
• Work with Amida Care provider network to ensure current clinical guidelines are widely distributed.
• Educate providers regarding Plan benefits, UM policies, and clinical criteria.
• Educate members and providers regarding Plan benefits, policies, and support services available to members.
• Perform regular cases reviews and member rounds in accordance with Amida Care’s Model of Care.
• Communicate request outcomes to members, including approvals and denials.
• Prepare for and attend interdisciplinary case conferences regarding surgical care plan.
• Serve as point of contact for inquiries regarding surgical requests from members, colleagues, and providers.
• Engage members and providers when a need is identified that will support improved health outcomes for the behavioral and physical health of members of transgender experience.
• Review clinical documentation, claims/utilization data to ensure members are receiving appropriate care and implement strategies to address unmet needs as appropriate.
• Conduct needs assessments to determine appropriate referrals and supports.
  
  

Amida Care is Diversity, Equity and Inclusion employer committed to full inclusion and elimination of discrimination in all its forms. We strive to develop, promote and sustain a culture that values equity and leverages diversity and inclusiveness in all that we do.

Amida Care requires that all candidates selected for employment must provide proof of full Covid-19 Vaccination upon acceptance of an offer of employment.

Education Required

• Registered Nurse
  
  

Experiences And/Or Skills Required

• Two (2) years’ population health and/or utilization management experience in a health care setting, preferred.
• Two (2) years’ experience working with the transgender community, preferred.
• Knowledge of transgender surgical procedures, preferred.
• Two (2) years’ health care or managed care experience, preferred.
• Bilingual (English/Spanish) preferred.
• Strong knowledge of Microsoft Office (Access, Word and Excel).
• Demonstrate understanding and sensitivity to multi-cultural values, beliefs, and attitudes of both internal and external contacts.
• Demonstrate appropriate behaviors in accordance with the organization’s vision, mission, and values.
• All candidates must include a cover letter for consideration