Licensed Utilization Review I
4 days ago
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.
-
Licensed Utilization Review I
2 days ago
Miami, FL, United States Elevance Health Full timeLicensed 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...
-
Licensed Utilization Review Specialist
2 days ago
Miami, Florida, United States Elevance Health Full timeJob Title: Licensed Utilization Review IAt Elevance Health, we are seeking a highly skilled Licensed Utilization Review I to join our team. As a key member of our healthcare team, you will play a critical role in ensuring the appropriate and consistent administration of plan benefits.Job Summary:The Licensed Utilization Review I is responsible for working...
-
Miami, United States Jackson Health Full timeDepartment: Jackson Memorial Hospital - Utilization Review Case Management (two openings)Address: 1611 NW 12 Ave, Miami, FL 33136Shift Details: 8:00 am - 4:30 pm, Monday-Friday with weekends occasionally (primarily remote)Why Jackson Memorial Hospital:Â Jackson Memorial Hospital is the flagship hospital for Jackson Health System and it has been a beacon of...
-
Utilization Review Specialist
6 days ago
Miami, Florida, United States Monte Nido & Affiliates, LLC Full timeJob SummaryMonte Nido & Affiliates, LLC is seeking a highly skilled Utilization Review Clinician to join our team. As a Utilization Review Clinician, you will play a critical role in ensuring that our patients receive the highest level of care by conducting thorough and comprehensive utilization reviews.Key ResponsibilitiesConduct utilization reviews, peer...
-
Utilization Review Specialist
6 days ago
Miami, Florida, United States Monte Nido & Affiliates, LLC Full timeAbout the RoleWe are seeking a highly skilled Utilization Review Clinician to join our team at Monte Nido & Affiliates, LLC. As a Utilization Review Clinician, you will play a critical role in ensuring that our patients receive the highest level of care while also navigating the complexities of the healthcare system.Key ResponsibilitiesConduct thorough and...
-
Licensed Utilization Review Senior
1 week ago
Miami, FL, USA, United States Elevance Health Full timeAbout the RoleWe are seeking a highly skilled Licensed Utilization Review Senior to join our team at Elevance Health. As a key member of our clinical review team, you will play a critical role in ensuring that our members receive the most appropriate and cost-effective care possible.Key ResponsibilitiesConduct thorough reviews of medical records to determine...
-
Miami, Florida, United States Jackson Health Full timeDepartment: Jackson Memorial Hospital - Utilization Review Case Management (two openings)Address: 1611 NW 12 Ave, Miami, FL 33136Shift Details: 8:00 am - 4:30 pm, Monday-Friday with weekends occasionally (primarily remote)Why Jackson Memorial Hospital: Jackson Memorial Hospital is the flagship hospital for Jackson Health System and it has been a beacon of...
-
Clinical Coordinator
4 months ago
Miami, United States Jackson Health System Full timeJOB DESCRIPTION Department: Jackson Memorial Hospital - Utilization Review Case Management (two openings) Address: 1611 NW 12 Ave, Miami, FL 33136 Shift Details: 8:00 am - 4:30 pm, Monday-Friday with weekends occasionally (primarily remote) Why Jackson Memorial Hospital: Jackson Memorial Hospital is the flagship hospital for Jackson Health System and...
-
Oncology Utilization Review Specialist
4 days ago
Miami, Florida, United States University of Miami Full timeJob Summary:The University of Miami is seeking a skilled Oncology Utilization Review Specialist to join our team. As a key member of our healthcare team, you will be responsible for conducting thorough reviews of patient charts to ensure that medical services are necessary and meet established criteria.Key Responsibilities:Conduct timely prospective reviews...
-
Registered Nurse Case Manager
3 weeks ago
Miami, United States Public Health Trust of Dade Co Full timeDepartment: Public Health Trust of Dade Co - Case Management, Utilization ReviewShift Details:Per Diem, Day Shift, 8:00 am-4:30 pm (Remote work available during weekdays, 4 shifts per month)About Public Health Trust of Dade Co: The Public Health Trust of Dade County is dedicated to providing exceptional healthcare services and community support. With a...
-
Miami, United States Jackson Health Full timeDepartment: Jackson Memorial Hospital - Utilization Review Case Management LeadershipAddress: 1611 NW 12 Ave., Miami, FL 33136Shift details: 8:00 - 4:30 PM, Monday - Friday (remote position, must live within one hour from facility)Â Why Jackson Memorial Hospital:Â Jackson Memorial Hospital is the flagship hospital for Jackson Health System and it has...
-
Miami, United States Jackson Health Full timeDepartment: Jackson Memorial Hospital- Case Management, Utilization Review Address: 1611 NW 12 Ave, Miami, FL 33136Shift details: Per Diem, Day Shift, 8:00 am-4:30 pm (Local remote, available to work during the week, 4 shifts per month)Why Jackson Memorial Hospital: Jackson Memorial Hospital is the flagship hospital for Jackson Health System and...
-
Miami, United States Jackson Health Full timeDepartment: Jackson Memorial Hospital - CCC Case Management Utilization ReviewAddress: 1611 NW 12 Ave, Miami, FL 33136Shift details: Full time, Days Why Jackson Memorial Hospital: Jackson Memorial Hospital is the flagship hospital for Jackson Health System and it has been a beacon of medical excellence and community care for more than a century....
-
Document Reviewer
1 hour ago
Miami, Florida, United States KLDiscovery Full timeJob OpportunityKLDiscovery is seeking a skilled Document Reviewer to join our team. As a Document Reviewer, you will play a critical role in supporting our clients' litigation needs by reviewing and coding documents for relevancy, confidentiality, and privilege.Key ResponsibilitiesReview and code documents using electronic review platforms, such as Nebula...
-
Miami, United States Public Health Trust of Dade Co Full timeDepartment: Jackson Memorial Hospital- Case Management, Utilization Review Address: 1611 NW 12 Ave, Miami, FL 33136 Shift details: Per Diem, Day Shift, 8:00 am-4:30 pm (Local remote, available to work during the week, 4 shifts per month) Why Jackson Memorial Hospital: Jackson Memorial Hospital is the flagship hospital for Jackson Health System and it has...
-
Newly Licensed Real Estate Sales Agent
2 weeks ago
Miami, Florida, United States The I Love Hammock Beach Team Full timeJob DescriptionJob Summary:The I Love Hammock Team is seeking a highly motivated and ambitious Real Estate Sales Agent to join our dynamic team. As a key member of our team, you will be responsible for delivering exceptional service and outstanding results for our clients.About the Role:We are looking for a talented and driven individual who is passionate...
-
Miami, United States Public Health Trust of Dade Co Full timeDepartment: Jackson Memorial Hospital - Utilization Review Case Management Leadership Address: 1611 NW 12 Ave., Miami, FL 33136 Shift details: 8:00 - 4:30 PM, Monday - Friday (remote position, must live within one hour from facility) Why Jackson Memorial Hospital: Jackson Memorial Hospital is the flagship hospital for Jackson Health System and it has been a...
-
Accounts Receivable Specialist
2 weeks ago
Miami, Florida, United States Denovo Review Full timeJob DescriptionDenovo Review, a leading provider of financial services, is seeking a highly skilled Financial Collections Professional to join their team. The ideal candidate will support the administration of collection activities for assigned clients, practice groups, and/or billing attorneys.Key Responsibilities:Collaborate with assigned attorneys to...
-
Licensed Practical Nurse I
3 hours ago
Miami, Florida, United States COMMUNITY HEALTH of SOUTH DADE, Inc. Full timeJob SummaryWe are seeking a highly skilled Licensed Practical Nurse I to join our team at Community Health of South Dade, Inc. As a key member of our healthcare team, you will provide exceptional nursing care to our patients, working under the supervision of a skilled RN. If you are a compassionate and detail-oriented LPN with excellent communication skills,...
-
Miami, United States @Orchard Full timeJob DescriptionJob DescriptionBilingual Intellectual/Developmental Disabilities Quality Assurance ReviewerMust reside in the Miami, FL area@Orchard LLC is retained by a not-for-profit corporation that partners with public and private sectors to create high quality, safe, and efficient delivery of health care and human services programs. We have multiple...
