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About the Role
The Utilization Management (UM) Nurse for Gender Affirming Services (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 UM determinations in conjunction with Clinical Services, 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.
- 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.
Requirements
- Two (2) years’ utilization management experience in a health plan setting.
- Strong knowledge of Microsoft Office (Access, Word and Excel).
- Two (2) years’ experience working with the transgender community.
- Knowledge of transgender surgical procedures.
- Two (2) years’ health care or managed care experience.
- Bilingual (English/Spanish).
- 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.
Skills
- Utilization management
- Microsoft Office (Access, Word, Excel)
- Working with the transgender community
- Transgender surgical procedures
- Health care
- Managed care
- Bilingual (English/Spanish)
- Understanding and sensitivity to multi-cultural values
- HIPAA
Location
- NY
Work Type
- Full-time
Experience Level
- 2 years utilization management experience
- 2 years experience working with the transgender community
- 2 years health care or managed care experience
Education Level
- NYS Licensed Registered Nurse
Salary/Compensations
- Commensurate with experience
About the Company
- Amida Care is the largest Medicaid HIV Special Needs Plan in NY, delivering a uniquely effective care model that has become a true benchmark for innovation, engagement and member health outcomes.
- Our mission is to provide access to comprehensive care and coordinated services that facilitate positive health outcomes and general well-being for our members.
- This true integrative care model addresses psychosocial, housing, behavioral and medical services directly evolving around the needs of each member.
- We are a community of individuals from diverse peoples who work together to actively foster a fair, equitable, inclusive environment where all employees receive an invitation to belong.
- Visit http://www.amidacareny.org [http://www.amidacareny.org] for more information about the Amida Care culture.
Equal Opportunity
- Amida Care is Diversity, Equity and Inclusion employer committed to full inclusion and elimination of discrimination in all its forms.
- We strive to develop, promote and sustain a culture that values equity and leverages diversity and inclusiveness in all that we do.