Utilization Review Nurse
VillageCare is looking for a self‑motivated and passionate RN for a full‑time, 100% remote position.
Location: Must reside within the New York Tri‑State Area (NY, NJ, or CT).
From the comfort of your own home, you will be responsible for the assessment of member needs and the identification of solutions that promote high quality and cost‑effective health care services. Some of your daily activities will include:
Reviews planned, in process, or completed health care services to ensure medical necessity and effectiveness according to evidence‑based criteria—prospective, concurrent, and retrospective review.
Frequently collaborates and communicates with physician peer reviewers and medical directors to determine coverage of requested services.
Provides intervention and coordination to decrease delays and denials.
Maintains timely, complete, and accurate documentation in compliance with VCMAX policies and procedures.
Supports Quality and Performance Improvement initiatives.
Timely follow‑up on results of denial and internal appeal reviews.
We would like to speak to applicants who have a current unrestricted NYS RN license (URAC preferred) and a BSN (advanced degree preferred). Applicants must have at least 2+ years of utilization review experience at a Managed Care Organization or Health Plan, inpatient experience required, and experience with MLTC and Hospital/SNF. Working knowledge of Medicaid and/or Medicare regulations and coverage guidelines is required.
Benefits include:
PTO package, 10 paid holidays, personal and sick time, medical/dental/vision, HRA/FSA, education reimbursement, retirement savings 403(b), life & disability, commuter benefits, paid family leave, additional employee discounts.