Utilization Management LPN

4 weeks ago


Doral, United States Actalent Full time

Utilization Management Nurse

Job Description

The role of the Utilization Management (UM) Nurse is to promote quality, cost-effective outcomes for a population by facilitating collaboration and coordination across settings, identifying member needs, planning for care, monitoring the efficacy of interventions, and advocating to ensure members receive the services and resources required to meet desired health and social outcomes. The UM Nurse is responsible for providing patient-centered care across the care continuum.

Responsibilities

+ Perform prospective, retrospective, or concurrent medical necessity reviews for an assigned panel of members.

+ Review cases for medical necessity and apply the appropriate clinical criteria, including but not limited to Medicare criteria, Medicaid/Medi-cal criteria, Interqual, Milliman, or Health Plan specific guidelines.

+ Collaborate with the Medical Director to ensure the integrity of adverse determination notices based on quality standards for adverse determinations.

+ Ensure timely and appropriate discharge planning is communicated to the transition of care teams, when applicable.

+ Meet or exceed productivity targets set forth.

+ Serve as a resource to non-clinical team members when applicable.

Essential Skills

+ Clinical review

+ Utilization management

+ Concurrent review

+ Utilization review

+ Prior authorization

+ Health care

+ Medicaid

+ Medicare

+ Milliman commercial guidelines

+ Interqual

Additional Skills & Qualifications

+ Associate's degree in Nursing

+ Active LVN/LPN license in the state of California

+ Minimum 2 years of experience in prospective clinical review/prior authorizations and retrospective review

+ Clinical experience in high-acuity areas (med-surg, ED, CCU, ICU, etc.)

+ Experience with Medicare and Medicaid clinical reviews

+ Working knowledge of MCG and NCQA standards

+ Working knowledge of InterQual preferred

Work Environment

100% onsite in Doral, FL. Shift: Sunday-Thursday, 8am-5pm. Occasional Saturday coverage needed; some flexibility available with supervisor's approval. Candidates with Saturday availability will be given preference due to fluctuating case volumes.

About Actalent

Actalent is a global leader in engineering and sciences services and talent solutions. We help visionary companies advance their engineering and science initiatives through access to specialized experts who drive scale, innovation and speed to market. With a network of almost 30,000 consultants and more than 4,500 clients across the U.S., Canada, Asia and Europe, Actalent serves many of the Fortune 500.

Diversity, Equity & Inclusion

At Actalent, diversity and inclusion are a bridge towards the equity and success of our people. DE&I are embedded into our culture through:

+ Hiring diverse talent

+ Maintaining an inclusive environment through persistent self-reflection

+ Building a culture of care, engagement, and recognition with clear outcomes

+ Ensuring growth opportunities for our people

The company is an equal opportunity employer and will consider all applications without regard to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.

If you would like to request a reasonable accommodation, such as the modification or adjustment of the job application process or interviewing process due to a disability, please email actalentaccommodation@actalentservices.com (%20actalentaccommodation@actalentservices.com) for other accommodation options.



  • Doral, United States Actalent Full time

    Utilization Management Nurse Job Description The role of the Utilization Management (UM) Nurse is to promote quality, cost-effective outcomes for a population by facilitating collaboration and coordination across settings, identifying member needs, planning for care, monitoring the efficacy of interventions, and advocating to ensure members receive the...

  • Weekend Vent LPN

    3 weeks ago


    Doral, United States Maxim Healthcare Full time

    Maxim Healthcare in North Miami is hiring for a Licensed Practical Nurse (LPN) to work with Pediatric and/or Adult patients in their own homes. Why Join Maxim: * Competitive Pay & Weekly Paychecks * Health, Dental, Vision, HSA and Life Insurance * Paid Time Off * 401(k) Savings Plan * Maxcares Awards Program Responsibilities: * Utilize the nursing...

  • Sr. Sales Manager

    3 weeks ago


    Doral, United States Trump Miami Resort Management LLC Full time

    POSITION PURPOSE: Represents the hotel in the development of market segment(s) and new customer relationships while maintaining existing relationships with assigned accounts while consistently striving to maximize revenue in rooms, public space, food and beverage and ancillary products and services. EXAMPLES OF DUTIES:ESSENTIAL FUNCTIONS: Average Percent of...

  • Director of Sales

    3 weeks ago


    Doral, United States Trump Miami Resort Management Llc Full time

      POSITION PURPOSE: Lead the development and execution of strategic Sales and Marketing Plans and initiatives that maximize profitability for the hotel in order to achieve budget, revenue and market share targets. EXAMPLES OF DUTIES:  Direct the resort in the development, implementation and achievement of their annual  business and market plan...


  • Doral, United States Vensure Employer Solutions Full time

    Position Summary As a Customer Success Manager, youll be the beacon guiding hotel clients through their transition from traditional methods to their innovative digital platform. You will be responsible for establishing a strong relationship with new prospects as well as maintaining a strong relationship with existing accounts. Your effective communication...


  • Doral, United States Syneos Health inVentiv Health Commercial LLC Full time

    Description You have what it takes: a competitive drive coupled with exceptional sales ability. In this role, you will implement the sales plan by delivering proficient sales presentations to a defined list of current and prospective customers. You will: Meet and/or exceed performance objectives in an assigned territory by developing, implementing, and...


  • Doral, United States Scion Staffing Full time

    Job DescriptionJob DescriptionScion Staffing has been engaged to conduct an immediate search for an experienced Creative Strategy Manager to join our partner, a growing E-commerce company in South Florida! This is a remote, full-time position that offers competitive pay and the chance to provide proactive leadership to an engaged creative team!The ideal...

  • Traffic Manager

    4 weeks ago


    Doral, Florida, United States AWP Safety Full time

    At AWP Safety, we're committed to delivering exceptional service and protection to our clients. As a Traffic Manager - Road Safety Specialist, you'll play a crucial role in ensuring the safety of all on the jobsite. This includes establishing and maintaining safe work zones using the proper equipment and collaborating with team members to guarantee the...


  • Doral, United States Reeco Full time

    About Us Welcome to Reeco, where were transforming the back-of-house tech for the hospitality industry. Think of it like this: while hotels are all about luxury and convenience, their operations are often stuck in the 90s. From emailing suppliers to doing inventory with pen and paper its outdated, inefficient, and expensive. Thats where we come in! With the...


  • Doral, United States University of Miami - UHealth Full time

    Regional Anesthesia and Acute Pain Management Anesthesiologist Job Description: The Department of Anesthesiology, Perioperative Medicine and Pain Management at the University of Miami Miller School of Medicine (UMMSOM) is experiencing a period of expansion and is seeking exceptional candidates to join the faculty.?? The University of Miami is considered...


  • Doral, United States Trump Miami Resort Management LLC Full time

    POSITION PURPOSE: Represents the hotel in the development of market segment(s) and new customer relationships while maintaining existing relationships with assigned accounts while consistently striving to maximize revenue in rooms, public space, food and beverage and ancillary products and services. EXAMPLES OF DUTIES:ESSENTIAL FUNCTIONS: Represent hotel by...


  • Doral, United States Scion Staffing Full time

    Job DescriptionJob DescriptionScion Staffing has been engaged to conduct an immediate search for an experienced E-Commerce Strategy Manager to join our partner, a growing E-commerce company in South Florida! This is a remote, full-time position that offers competitive pay and the chance to provide proactive leadership to an engaged creative team!The ideal...

  • Hydraulic Modeler

    4 weeks ago


    Doral, Florida, United States Nova Consulting Full time

    Job SummaryNova Consulting is seeking a skilled Hydraulic Modeler to join our team of professionals in the field of water and wastewater systems. As a Hydraulic Modeler, you will be responsible for conducting hydraulic computations and computer modeling of water, wastewater, and stormwater systems.Key Responsibilities:Data collection and analysis,...

  • Industrial Engineer

    2 weeks ago


    Doral, United States Syncreon Full time

    syncreon by DP World delivers tailored, scalable and progressive solutions to customers in more than 100 global locations. The company has managed supply chain synergies for global automotive and technology premier brands for more than 60 years. Do you feel energized from designing, running, testing and upgrading engineering systems and processes? Then the...

  • Bookkeeper

    2 months ago


    Doral, United States SNI Financial Full time

    Seeking Accounting/Bookkeeping Professionals in the Doral, Hialeah and Medley areas!We are seeking a detail-oriented Bookkeeper(s).Will be responsible for maintaining financial records. Bi-lingual, English/Spanish highly preferred. Responsibilities - Perform balance sheet reconciliations - Utilize QuickBooks for bookkeeping tasks - Involvement with...


  • Doral, United States The University of Miami Full time

    Current Employees:If you are a current Staff, Faculty or Temporary employee at the University of Miami, please click here to log in to Workday to use the internal application process. To learn how to apply for a faculty or staff position using the Career worklet, please review this tip sheet.Per DiemCRNALocation: DoralUHealth at Doral has Per Diem...


  • Doral, Florida, United States EFL Full time

    Job OverviewWe are seeking a highly professional and organized Administrative Support Partner to provide comprehensive support to our senior leadership team, including the COO, Head of Ocean Product, and multiple VPs. This role is crucial in ensuring the smooth day-to-day operations of multiple executives in the supply chain logistics industry, with...


  • Doral, United States University of Miami - UHealth Full time

    Regional Anesthesia and Acute Pain Management Anesthesiologist Job Description: The Department of Anesthesiology, Perioperative Medicine and Pain Management at the University of Miami Miller School of Medicine (UMMSOM) is experiencing a period of expansion and is seeking exceptional candidates to join the faculty. The University of Miami is considered among...

  • Sales Associate

    3 months ago


    Doral, United States Chico's Full time

    Join our fashion-obsessed team, dedicated to a styling and social experience that makes women feel beautiful. POSITION OBJECTIVE: The Sales Associate is responsible for supporting Management in in promoting a customer and product-focused sales culture, where our values and guiding principles are at the forefront of all store operations, including ensuring a...

  • Sales Associate

    6 months ago


    Doral, United States Chico's Full time

    With approximately 1,300 boutiques and outlets throughout the U.S., as well as an online presence for each of our brands, it takes sophisticated technology, resources and infrastructure to ensure the continued success of our businesses. From finance and accounting to technology and merchandising careers, we have diverse opportunities available for talented...