Nurse Case Manager Appeals (Utilization Management)

NEW YORK, NYPosted a month ago

Job summary

• Job post source

  This job is directly from 1199SEIU Benefit and Pension Funds

• Job overview

  The Nurse Case Manager Appeals (Utilization Management) role involves assessing and managing healthcare service delivery through case management to ensure medical necessity and compliance with benefit plans.

• Responsibilities and impact

  The nurse will perform medical necessity reviews, manage appeals, prepare cases for external review, apply clinical guidelines, maintain records, authorize vendor services, and support care management programs to ensure quality and efficiency.

• Experience and skills

  Candidates must have an Associate or Bachelor's degree, valid NY State RN or LPN license, at least three years of Medical/Surgical experience, two years in Utilization Management, and proficiency with UM criteria and clinical assessment skills; Case Management certification is a plus.

• Company information

  1199SEIU Benefit and Pension Funds is a fund managing benefits and pensions for healthcare workers, focusing on quality and efficient clinical operations.

• Job location and travel

  The position is full-time, permanent, and hybrid work arrangement within the 1199SEIU National Benefit Fund.

• Unique job features

  The role involves working with complex clinical cases including advanced therapies and requires use of multiple clinical guidelines and coordination with medical consultants.

Company overview

1199SEIU Benefit and Pension Funds is a prominent organization that provides comprehensive health and pension benefits to healthcare workers affiliated with the 1199SEIU United Healthcare Workers East union. They generate revenue through contributions from participating employers and manage these funds to ensure the financial security and well-being of their members. Established in the mid-20th century, the organization has a rich history of advocating for workers' rights and improving healthcare benefits, making it a key player in the labor and healthcare sectors.

How to land this job

• Position your resume to highlight your clinical expertise in medical necessity reviews, utilization management, and case coordination, showcasing your ability to apply Milliman Care Guidelines and vendor clinical policies.

• Emphasize your experience with appeals processes, including first and second-level appeals, urgent appeals, and preparing cases for external Independent Review organizations, demonstrating strong critical thinking and clinical summary skills.

• Apply through multiple platforms such as the 1199SEIU Benefit and Pension Funds corporate website and LinkedIn to maximize your application visibility and increase your chances of being noticed.

• Connect with current Nurse Case Managers or Utilization Management professionals at 1199SEIU Benefit and Pension Funds on LinkedIn; start conversations with ice breakers like asking about recent changes in utilization management guidelines or their experience working with Milliman Care Guidelines.

• Optimize your resume for ATS by incorporating keywords from the job description such as 'medical necessity review,' 'utilization management,' 'Milliman Care Guidelines,' 'case management,' and 'prior authorization' to ensure your resume passes automated screenings.

• Utilize Jennie Johnson's Power Apply feature to automate application submissions across multiple platforms, tailor your resume for ATS, and identify LinkedIn contacts for networking, freeing up your time to focus on interview preparation and skill enhancement.