Utilization Management Coordinator
2 weeks ago
Under the general supervision of the Director of Health Services, the position is responsible for appropriately and successfully executing clinical and administrative health plan denials in accordance with regulatory guidelines and plan policies. ESSENTIAL DUTIES AND RESPONSIBILITIES 1. Is responsible for managing all denials by conducting a comprehensive review of clinical documentation, clinical criteria/evidence-based guideline, policy, and or EOC/benefit policy. 2. Processes Medical Director or Behavior Health Practitioner denials in accordance with regulatory guidelines and plan policies. 3. Formulates a clear and concise clinically based or administrative argument to denial rationales supported by clinical criteria, including but not limited to, CMS, Florida Medicaid, CFR, Health Plan, InterQual (IQ), Milliman Care Guidelines (MCG), and UpToDate. 4. Complies with company and department policies and procedures to ensure timely and denials. 5. Follows Medicare/Medicaid's denial rationale best practices. 6. Educates clinical and non-clinical staff within the guidelines of Leon Health's policies and procedures and Medicare/Medicaid guidelines to assure competencies which are appropriate to accomplish duties and responsibilities productively and efficiently. 7. Monitors, evaluates, and prioritizes the quality, timeliness, and accuracy of prior authorization and concurrent denial reviews. 8. Is responsible for the data entry of denial decision communications to provider and members into the plan's system, when applicable, in accordance with regulatory guidelines and plan policies. 9. Refers cases requiring further clinical review to a Medical Director or Behavior Health Practitioner as appropriate. QUALIFICATIONS * Knowledge of Dual Eligible Special Needs Plans, Centers for Medicare and Medicaid Services (CMS), and Florida Medicaid * Understanding/experience with InterQual, Milliman Care Guidelines, and other criteria used for medical necessity determinations. EDUCATION * Registered Nurse degree. WORK EXPERIENCE * Minimum two (2) to five (5) years of experience in clinical reviews. * Medicare and/or Medicaid managed care experience
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Utilization Management Coordinator
1 month ago
Miami, United States Leon Health Full timeUtilization Management Coordinator (RN)Under the general supervision of the Director of Health Services, the position is responsible for appropriately and successfully executing clinical and administrative health plan denials in accordance with regulatory guidelines and plan policies. ESSENTIAL DUTIES AND RESPONSIBILITIES 1. Is responsible for managing all...
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Utilization Review Coordinator
1 month ago
Miami, Florida, United States Arista Recovery Full timeSUMMARY: The primary responsibility of this position is to implement the organization's Utilization Review(UR) process to ensure appropriate usage of available resources and to optimize reimbursement for services rendered following patient needs. The UR coordinator monitors the client population daily and regularly checks documentation for compliance with...
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Utilization Management Coordinator
2 months ago
Miami, FL, United States Leon Health Full timeUtilization Management Coordinator (RN) Under the general supervision of the Director of Health Services, the position is responsible for appropriately and successfully executing clinical and administrative health plan denials in accordance with regulatory guidelines and plan policies. ESSENTIAL DUTIES AND RESPONSIBILITIES 1. Is responsible for managing...
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Utilization Management Coordinator
2 months ago
Miami, FL, United States Leon Health Full timeUtilization Management Coordinator (RN) Under the general supervision of the Director of Health Services, the position is responsible for appropriately and successfully executing clinical and administrative health plan denials in accordance with regulatory guidelines and plan policies. ESSENTIAL DUTIES AND RESPONSIBILITIES 1. Is responsible for managing...
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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...
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Clinical Coordinator
2 weeks 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...
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Utility Category Manager
1 month ago
Miami, United States American Wire Group Full timeJob DescriptionJob DescriptionSalary: OverviewAmerican Wire Group (“AWG”), a leading supplier of insulated and bare wire and cable products, and services for infrastructure applications, specializes in renewable energy (wind and solar) and electric utility transmission, distribution, and substation products. AWG designs, manufactures, and markets...
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Utility Category Manager
1 month ago
Miami, United States American Wire Group Full timeJob DescriptionJob DescriptionSalary: Job Title: Category Manager – Utility Business LineLocation: Miami, FL, Chicago, IL, or Perris, CARemote: YesDepartment: ProcurementPosition Type: Full timeOverviewAmerican Wire Group (“AWG”), a leading supplier of insulated and bare wire and cable...
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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...
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Head Utility
1 week ago
Miami, United States Crew Life at Sea Full timeJob DescriptionJob DescriptionPosition Overview:As the Head Utility on a cruise ship, you will play a crucial role in overseeing the efficient operation of the utility department. Your responsibilities will include managing a team of utility personnel, coordinating maintenance and repair activities, and ensuring the smooth operation of essential ship...
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Utilization Management Coordinator
1 month ago
Miami, FL, United States Leon Health Full timeUtilization Management Coordinator (RN)Under the general supervision of the Director of Health Services, the position is responsible for appropriately and successfully executing clinical and administrative health plan denials in accordance with regulatory guidelines and plan policies. ESSENTIAL DUTIES AND RESPONSIBILITIES 1. Is responsible for managing all...
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Head Utility Galley
1 week ago
Miami, United States Crew Life at Sea Full timeJob DescriptionJob DescriptionPosition Overview:As the Head Utility Galley on a cruise ship, you will be responsible for overseeing and coordinating the utility galley operations. Your role will involve managing a team of utility galley staff, ensuring the cleanliness and proper maintenance of the galley, and supporting the efficient operation of the...
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Utilization Management Coordinator
1 month ago
Miami, United States Leon Medical Centers Full timeUnder the general supervision of the Director of Health Services, the position is responsible for appropriately and successfully executing clinical and administrative health plan denials in accordance with regulatory guidelines and plan policies. ESSENTIAL DUTIES AND RESPONSIBILITIES 1. Is responsible for managing all denials by conducting a comprehensive...
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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 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 it has been...
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Family Support Coordinator
2 weeks ago
Miami, United States Professional Management, Inc. Full timeJob DescriptionJob DescriptionFamily Support CoordinatorWe are currently seeking a Family Support Coordinator for high-rise property located in the Miami, Florida area.The Coordinator shall be on-site and available to residents at least 20 hours per week. The candidate should be able to coordinate resident activities at the property, assist residents with...
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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...
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Miami, Florida, United States Baptist Health South Florida Full timeBaptist Health South Florida is the largest healthcare organization in the region, with 12 hospitals, more than 24,000 employees, 4,000 physicians and 100 outpatient centers, urgent care facilities and physician practices spanning across Miami-Dade, Monroe, Broward and Palm Beach counties. Baptist Health has internationally renowned centers of excellence in...
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Miami, Florida, United States Baptist Health South Florida Full timeBaptist Health South Florida is the largest healthcare organization in the region, with 12 hospitals, more than 24,000 employees, 4,000 physicians and 100 outpatient centers, urgent care facilities and physician practices spanning across Miami-Dade, Monroe, Broward and Palm Beach counties. Baptist Health has internationally renowned centers of excellence in...
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Utilization Management
3 days ago
Miami, United States Solis Health Plans Full timeJob DescriptionJob DescriptionAbouts UsSolis Health Plans is a new kind of Medicare Advantage Company. We provide solutions that are more transparent, connected, and effective for both our members and providers. Solis was born out of a desire to provide a more personal experience throughout all levels of the healthcare journey. Our team consists of expert...
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Utilization Management
20 hours ago
Miami, United States Solis Health Plans Full timeJob DescriptionJob DescriptionAbouts UsSolis Health Plans is a new kind of Medicare Advantage Company. We provide solutions that are more transparent, connected, and effective for both our members and providers. Solis was born out of a desire to provide a more personal experience throughout all levels of the healthcare journey. Our team consists of expert...
