2 years of utilization management experience in a health plan setting.
Strong knowledge of Microsoft Office (Access, Word, Excel).
Experience working with the transgender community preferred.
Knowledge of transgender surgical procedures preferred.
2 years of healthcare or managed care experience preferred.
Bilingual (English/Spanish) preferred.
Responsibilities
Coordinate UM determinations with Clinical Services per regulatory guidelines.
Ensure timely completion of UM processes following all regulations.
Document all UM activities accurately in the database.
Distribute current clinical guidelines within the provider network.
Educate providers on Plan benefits and UM policies.
Facilitate member-driven pre- and post-surgery care coordination.
Engage members and providers to improve health outcomes for transgender individuals.
Benefits
Continuing education opportunities and seminars.
Supportive work environment focused on member-centered care.
Access to resources for professional development.
Commitment to diversity and inclusion in the workplace.
Full Job Description
We are actively seeking a highly motivated, innovative, experienced individual to join our team as the Utilization Management (UM) Nurse for Gender Affirming Services (GAS). Compensation will be commensurate with experience.
Position Summary:
The UM Nurse for GAS is responsible for reviewing and processing UM requests for gender affirming services in accordance with regulatory requirements, clinical guidelines, and established timeframes. This role partners with providers and members to ensure timely, appropriate, and member-centered care while educating stakeholders on plan benefits, UM policies, and gender affirming services to support positive health outcomes.
Responsibilities:
Coordinate, in conjunction with Clinical Services, 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.
Ensure pre- and post-surgery care coordination is member driven and supports increased health outcomes as applicable.
Educate members and providers regarding Plan benefits, policies, and support services available to members.
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.
When requested. review clinical documentation, claims/utilization data to ensure members are receiving appropriate care and implement strategies to address unmet needs as appropriate.
Provide member education on gender affirming procedures, hormone treatment and risk reduction strategies as appropriate.
Attend continuing education seminars, staff in-services and stay current with relevant literature to maintain familiarity with trends in transgender services.
Ensure member confidentiality and adheres to Confidentiality and Health Insurance Portability and Accountability Act (HIPPA) policies and regulations.
EDUCATION REQUIRED
NYS Licensed Registered Nurse
EXPERIENCES AND/OR SKILLS REQUIRED
Two (2) years' utilization management experience in a health plan setting, required.
Strong knowledge of Microsoft Office (Access, Word and Excel).
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.
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.
