Utilization Management Reviewer, RN

LTHC

Utilization Management Reviewer assessing behavioral and physical healthcare service necessity for Excellus BCBS members. Coordinating clinical reviews, providers, care management, and regulatory compliance.

Posted 8/5/2026full-timeAlbany • New York • 🇺🇸 United StatesMid-LevelSenior💰 $62,400 - $117,622 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in Utilization Management, including clinical reviews, compliance with State and Federal Mandates, and effective collaboration with healthcare providers. Proficient in coding standards and possesses strong communication skills to manage complex assignments and mentor staff.

Highest-signal resume keywords

Utilization ManagementClinical ReviewNYS RN LicenseMedicare and Medicaid KnowledgeMicrosoft Office Suite Proficiency

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical Review CriteriaUtilization Management StandardsCoding StandardsManaged Care Benefit Plans InterpretationPricing and Claims Research

Soft Skills

Strong Written CommunicationStrong Verbal CommunicationMultitaskingIndependent WorkMentoring

Certifications & Qualifications

Active NYS RN License

Industry Keywords

Behavioral Health ServicesPhysical Health ServicesQuality of CareAccreditation RequirementsHealthcare Collaboration

About the role

Key responsibilities & impact

Coordinate, integrate, and monitor utilization of behavioral health or physical health services for members
Perform pre-service, concurrent, and post-service clinical reviews to determine appropriateness and medical necessity of requested services
Apply clinical review criteria, guidelines, medical policies, contractual benefits, and State and Federal Mandates
Plan, implement, and document utilization management activities
Obtain clinical information from members and providers and interact with treating physicians and other care providers
Refer appropriate cases and potential quality-of-care or utilization issues to the Medical Director
Collaborate with hospitals, home care, care management, and other providers to prevent gaps in care
Act as a resource and liaison to the provider community
Perform pricing, coding, and claims research when assigned
Meet departmental timeliness, production, metrics, audit, regulatory, and accreditation requirements
Assist with training and special projects
Participate in rotating on-call schedules and work additional hours as needed
Level II: suggest process improvements, mentor staff, manage complex assignments, and participate in committees
Level III: provide leadership, resolve escalated issues, update procedures, mentor staff, support orientation and training, and provide supervisor backup

Requirements

What you’ll need

Associate degree and active NYS RN license required
Minimum of three (3) years of clinical experience required
Utilization Management experience preferred
Bachelor's degree preferred
Proficiency with Microsoft Office Suite
General understanding of coding standards
Current working knowledge of Utilization Management Standards
Experience interpreting managed care benefit plans preferred
Strong knowledge of Medicare and Medicaid contracts and benefits preferred
Strong written and verbal communication skills
Ability to multitask and balance priorities
Ability to work independently daily
Level II: minimum of 2 years in a utilization management position; ability to escalate issues, use related technology, assume broader responsibilities, and participate in training new staff
Level III: at least 5 years in a utilization management position or similar subject matter expert role; broad understanding of UM and CM; expertise handling complex assignments; ability to lead training; demonstrated presentation skills
Ability to travel independently within regions
Ability to work at a computer for prolonged periods

Benefits

Comp & perks

Group health and/or dental insurance
Retirement plan
Wellness program
Paid time away from work
Paid holidays
Potential opportunity for remote work on a case-by-case basis
Equal Opportunity Employer