Utilization Review Nurse
New York, New York County, New York, 10261, USA
Listed on 2026-01-19
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Nursing
RN Nurse, Healthcare Nursing, Clinical Nurse Specialist, Nurse Practitioner
Utilization Review Nurse – RN
Village Care is looking for a self‑motivated and passionate RN to serve as an Utilization Review Nurse for a full‑time remote position. The role is based in the New York Tri‑State Area (NY, NJ, CT) with the opportunity to work from home.
Responsibilities- Review planned, in‑process, or completed health care services to ensure medical necessity and effectiveness according to evidence‑based criteria – prospective, concurrent, and retrospective review.
- Collaborate and communicate with physician peer reviewers and medical directors in determining coverage of requested services.
- Provide intervention and coordination to decrease delays and denials.
- Maintain timely, complete, and accurate documentation in compliance with VCMAX policies and procedures.
- Support Quality and Performance Improvement initiatives.
- Timely follow‑up on results of denial and internal appeal reviews.
Required:
NYS RN license
, BSN (BSN or advanced degree preferred), and 2+ years of utilization review experience at a managed‑care organization or health plan. MUST have inpatient experience, MLTC and Hospital/SNF experience required. Working knowledge of Medicaid and/or Medicare regulations, coverage guidelines, and benefit limitations. Ability to apply Inter Qual/Milliman Care Guidelines and other evidence‑based clinical guidelines.
- 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.
Village Care offers a wide range of at‑home and community‑based services, as well as managed long‑term care options that seek to match each individual's needs to help them attain and maintain the greatest level of independent living possible. We are committed to superior outcomes in quality health care.
Village Care is an Equal Opportunity Employer.
Salary: $95,000 – $105,000 per year.
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