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Senior RN Utilization Review/Management
4 months ago
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.
- 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.
- 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.
Who We Are
Elevance Health is a health company dedicated to improving lives and communities - and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.
How We Work
At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.
We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.
Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. Candidates must reside within 50 miles or 1-hour commute each way of a relevant Elevance Health location.
The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.
Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact assistance.
