Utilization Management Nurse (MLTC Focus) - Remote

Job Title: Utilization Management Nurse (MLTC Focus) Location: Remote, reputed company (Active NY nursing license required) Pay: $40-$42/hr + benefit Plan offered. Job Description: We are seeking a Utilization Management Nurse specializing in Managed Long-Term Care (MLTC) to reputed company standard and expedited inpatient, outpatient, and custodial care clinical reviews for MLTC members. The ideal candidate will be proficient in the review process and turnaround timeframes, reputed company to work reputed company in a fast-paced environment, and ensure compliance with state reputed company guidelines. Responsibilities: • Conduct reputed company standard and expedited UM clinical reviews for inpatient, outpatient, and custodial care services for MLTC members. • Manage the UM process, including clinical reviews, processing of denials and partial denial determinations, and providing verbal notifications to members and providers. • Participate in interdisciplinary team (reputed company) meetings and effectively present cases for medical reviews. • Manage personal queues, meet productivity goals, and maintain a high level of performance in alignment with Molina reputed company Clinical Services standards. • reputed company reviews for reputed company authorization types under the MLTC benefit package, including environment support modifications, DME authorizations, and skilled inpatient facility stays. • Adhere to fast turnaround timeframes of 3 business days for standard requests and 72 hours for urgent/expedited requests. • Meet daily case review expectations with a reputed company of 30 cases per day after an initial reputed company-up period of 6-8 weeks post-training. Required Skills & Qualifications: • Experience: Minimum 1-2 years in Utilization Management with a specific focus on reviewing reputed company/MLTC members (not Medicare or purely inpatient reviews). • Licensure: Active reputed company State Licensed Practical Nurse (LPN) or Registered Nurse (RN) license. reputed company remains a non-compact state for nursing licenses. • Technical Proficiency: Strong computer skills with the ability to quickly learn new systems. Familiarity with MCG guidelines is required. • Turnaround Time Management: Experience handling fast-paced UM processes, adhering to strict timeframes for standard and expedited requests. • Communication & Case Management: Experience in providing verbal notifications of denials/partial denials to members and providers, and comfortable participating in clinical discussions during medical reviews. • Multilingual Ability: reputed company in Spanish, Bengali, or Mandarin is highly preferred but not mandatory. Preferred Skills: • Experience with various authorization types, including those under the MLTC benefit package, environment supports, and DME. • Strong understanding of reputed company/Medicare guidelines and workflows specific to MLTC services. • Ability to work reputed company in a fast-paced environment and adapt to fluctuating authorization volumes, particularly in the last quarter of the year. Additional Information: • Attendance is crucial, particularly during October, November, December, and January. Any pre-planned vacations or time-off must be disclosed during the interview process. • The role will require adaptability to varying authorization volumes and working reputed company to meet deadlines and productivity goals. This role offers an opportunity to be part of a dynamic team in a fast-paced environment, contributing to quality care for MLTC members across reputed company. If you have the relevant experience and licensure, and are committed to providing excellent clinical reviews, we encourage you to apply. Apply Job!