Utilization Management Professional

Doral, FL

Post Date: 07/11/2017 Job ID: 22505 Category: Registered Nurse

  • The candidate will work an 8 hour shift that could start between the hours of 8am 10: 30am.

Job Description:
  • Under general supervision by management, and in collaboration with Medical Directors and other members of the clinical team, gathers and synthesizes clinical information in order to authorize services.
  • Reviews health care services to determine consistency with contract requirements, coverage policies and evidence-based medical necessity criteria.
  • Collects and analyzes utilization information; assists with program processes for transitions across levels of care including discharge planning and ambulatory follow up activity.
  • Serves as an expert resource on coverage policies, covered benefits, and medical necessity criteria.
  • Caseload: 25-30 reviews per day.
  • This position is 98% telephonic.
  • There will be rounds with a Doctor for 15 mins every day.


  • Develops and manages new enrollee transitions and those involving a change in provider relationships.
  • Develops and implements transition plans, as indicated, to ensure continuity of care.
  • Negotiates and documents single case agreements according to the company s procedures.
  • Reviews planned, in process, or completed health care services to ensure medical necessity and effectiveness according to evidence-based criteria.
  • Proposes alternatives when the requested services do not meet medical necessity criteria or are outside the contracted network.
  • As assigned and based on credentials, monitors and reviews specialized requests and treatment records such as Treatment Record Forms.
  • In conjunction with providers and facilities, identifies, develops and monitors discharge plans.
  • Collaborates with the Care Coordination Team to implement support for transitions in care.
  • Facilitates timely sharing of enrollees clinical information (such as previous treatment, medications, and planned care) in order to promote continuity of care.
  • Provides information to enrollees, providers, and internal staff regarding covered and non-covered benefits, community resources, agency programs, and company policies and procedures and criteria.
  • Interacts with Medical Directors and Physician Advisors to provide case information and discuss clinical and authorization questions and concerns regarding specific cases.
  • Assures that case documentation for each decision is complete, including related correspondence.
  • Participates in Care Coordination Team and utilization management activities, including collaboration with other staff on enrollee cases, and performing data collection, tracking, and analysis.
  • Maintains an active work load in accordance with performance standards.
  • Works with community agencies as appropriate.
  • Participates in network development including identification and recruitment of quality providers as needed.
  • Advocates for the enrollee to ensure health care needs are met. Interacts with providers in a professional, respectful manner.
  • Provides coverage of Nurse Line and/or Crisis Line as requested or required for position.

Experience & Education:
  • Master's Degree.
  • MUST have BH experience.
  • The manager is looking for 3 years of Inpatient Medical experience, 3 years of Utilization experience, Concurrent Review experience and HMO exp.
  • Training will be 3 4 weeks long that will include Magellan Code of Conduct, Systems App and Shadowing.
  • Credentialing Paperwork will be completed during training.

License Requirements:
  • LCSW, LCPC or RN.
  • A Master s degree is required for ALL licenses EXCEPT for the RN.
  • A Bachelor s degree is required for the RNs.

A-Line Staffing Solutions



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