Senior RN Utilization Review/Management (Acute InPatient) JR116937

Location: Must be within 50 miles / 1 hour commute of Tampa or Miami, FL offices. This is primarily a remote position but may be required to go in for meetings/training.

MUST RESIDE IN THE STATE OF FLORIDA.

Work Hours: 8am – 5pm, Monday – Friday. 2 Holidays per year and occasional weekends.

The Nurse Medical Management Sr serves as team lead for nursing staff who collaborate with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources for the most complex or elevated medical issues. Ensures medically appropriate, high quality, cost effective care through assessing the medical necessity of inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting by utilizing the applicable medical policy and industry standards, accurately interpreting benefits and managed care products, and steering members to appropriate providers, programs or community resources. Works with medical directors in interpreting appropriateness of care and accurate claims payment. May also manage appeals for services denied. Primary duties may include, but are not limited to:

• Continued stay review, care coordination, and discharge planning for appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.

• Conducts precertification, continued stay review, care coordination, or discharge planning for appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.

• Ensures member access to medical necessary, quality healthcare in a cost-effective setting according to contract.

• Consult with clinical reviewers and/or medical directors to ensure medically appropriate, high quality, cost-effective care throughout the medical management process.

• Collaborates with providers to assess members needs for early identification of and proactive planning for discharge planning.

• Facilitates member care transition through the healthcare continuum and refers treatment plans/plan of care to clinical reviewers as required and does not issue non-certifications.

• Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards.

• Ensures consistency in benefit application.

• May lead cross-functional teams, projects, initiatives, and process improvement activities.

• May serve as departmental liaison to other areas of the business unit or as representative on enterprise initiatives.

• Assigns and audits daily work of other nurses.

• Functions as a SME for the team.

Minimum Requirements:

• Current active unrestricted RN license in the state of Florida.

• Requires minimum of 5 years acute care clinical experience, utilization management or managed care experience; or any combination of education and experience, which would provide an equivalent background.

Preferred Qualifications:

• Experience working in the health insurance / managed care industry strongly preferred .

• 2 years of experience in In-Patient, utilization review / management, evaluating medical necessity for services and procedures.

• Knowledge of medical management process and ability to interpret and apply member contracts, member benefits, and managed care products.

• Experience leading, mentoring, coaching a team (direct or indirect reports.)

• Flexible, able to change priorities midstream in fast paced environment.

• Proficient in use of Microsoft Word, Excel, and Outlook.