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Licensed Utilization Review I

2 months ago

Miami FL United States Elevance Health Full time
Licensed Utilization Review I (RN)

Anticipated End Date: 2024-09-21 Position Title: Licensed Utilization Review I (RN) Job Description: Simply Healthcare Plans, Inc. is a proud member of Elevance Health's family of brands. We are a licensed health maintenance organization with health plans for people enrolled in Medicaid and/or Medicare programs in Florida. Licensed Utilization Review I Location: This is a remote position. The selected candidate must reside in the state of Florida. This position requires level 2 background check. Schedule: This position will work a 1st shift from 8:00 am- 5:00 pm (EST), Monday thru Friday. Additional hours or days may be required based on operational needs (holiday and weekend rotation). The Licensed Utilization Review I is responsible for working with healthcare providers to help ensure appropriate and consistent administration of plan benefits through collecting clinical information to preauthorize services, assess medical necessity, out of network services, and appropriateness of treatment setting and applying appropriate medical policies, clinical guidelines, plan benefits, and/or scripted algorithms within scope of licensure. How you will make an impact Primary duties may include, but are not limited to: * Conducts pre-certification, inpatient (if not associated with CM or DM triage) retrospective, out of network and appropriateness of treatment setting reviews within scope of licensure by utilizing appropriate medical policies and clinical guidelines in compliance with department guidelines and consistent with the members eligibility, benefits and contract. * Develops relationships with physicians, healthcare service providers, and internal and external customers to help improve health outcomes for members. * Applies clinical knowledge to work with facilities and providers for care coordination. * May access and consult with peer clinical reviewers, Medical Directors and/or delegated clinical reviewers to help ensure medically appropriate, quality, cost effective care throughout the medical management process. * Educates the member about plan benefits and contracted physicians, facilities and healthcare providers. * Refers treatment plans/plan of care to peer clinical reviewers in accordance with established criteria/guidelines and does not issue medical necessity non-certifications. * Facilitates accreditation by knowing, understanding, and accurately applying accrediting and regulatory requirements and standards. Minimum Requirements: * Requires a HS diploma or equivalent and a minimum of 2 years of clinical or utilization review experience with long term care population; or any combination of education and experience, which would provide an equivalent background. * Current active unrestricted license or certification as a LPN, LVN, or RN to practice as a health professional within the scope of licensure in applicable state(s) or territory of the United States required. Preferred Skills, Capabilities, and Experiences: * Bachelor's degree in nursing is highly preferred. * Current active unrestricted license or certification as a RN practice as a health professional within the scope of licensure in applicable state of Florida. * Previous Medical Review and/or Prior Authorization/Pre-Certification experience is preferred. * Certification in the American Association of Managed Care Nurses is preferred. * Knowledge of the medical management processes and the ability to interpret and apply member contracts, member benefits, and managed care products is strongly preferred. * Long Term Care Prior utilization/medical review experience is strongly preferred. * Proficient in Microsoft Office For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills. Job Level: Non-Management Non-Exempt Workshift: 1st Shift (United States of America) Job Family: MED > Licensed Nurse Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health. 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 elevancehealthjobssupport@elevancehealth.com for assistance.