Utilization Management Professional
Orlando, FL 32812
- Under general supervision, 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.
- 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.
- Requirement to work 1-2 weekends per month, but will get one weekday off work in exchange.
- RN in the state of Florida.
- Bachelor s or Master s Level of Education Required.
- 3 years experience post degree in a clinical, psychiatric and/or substance abuse health care setting.
- Also requires minimum of 3 years of experience conducting utilization management according to medical necessity criteria.
- Ability to use computer systems.
- Good organization, time management and verbal and written communication skills.
- Knowledge of utilization management procedures, Medicaid benefits, community resources and providers.
- Knowledge and experience in diverse patient care settings including inpatient care.
- Ability to function independently and as a team member.
- Knowledge of ICD and DSM IV coding or most current edition.
- Ability to analyze specific utilization problems and creatively plan and implement solutions.
- Able to demonstrate the ability to quickly develop an alliance with providers via telephone.
- On call coverage of Nurse Line as requested or required of position.
For more information on this position, please contact our office at 877-782-3334.