Utilization Management Professional

Orlando, FL 32812

Post Date: 08/01/2018 Job ID: 28414 Category: Registered Nurse

  • 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.

Essential Functions:
  • 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.


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