Utilization Management Nurse

1 week ago


Sunrise Manor, Nevada, United States HealthCare Support Full time
Job Title: Utilization Management Nurse

We are seeking a skilled Utilization Management Nurse to join our team at HealthCare Support. As a Utilization Management Nurse, you will play a critical role in ensuring that our patients receive the most appropriate and cost-effective care.

Responsibilities:
  • Review prior authorization requests for medical necessity and appropriateness, utilizing standardized Review Criteria.
  • Coordinate with the Medical Director/Physicians for those requests outside of standard Review Criteria.
  • Maintain compliance with federal and state guidelines as well as contractual requirements as determined by line of business.
  • Obtain necessary documentation and ensure completion of assigned caseload by addressing discrepancies and following up until a determination is achieved.
  • Serve as a liaison between the Medical Director, physicians and office staff in resolving prior authorization questions, issues and problems.
  • Communicate denial determinations to providers when indicated.
  • Perform evaluation and concurrent monitoring of appropriate utilization of resources.
  • Provide current and timely documentation reflecting department work processes and policy guidelines.
  • Promote safe and appropriate coordination of care.
  • Promote, facilitate, and control the optimal utilization of resources, consistent with organizational goals.
  • Identify and participate in the development of programs, policies, and procedures to promote continuous quality improvement.
  • Assure adherence to company and department policies and procedures regarding confidentiality.
  • Participate in regular departmental training.
  • Serve as a plan liaison to coordinate enrollee benefits with providers and/or external organizations.
  • Prepare and present reports on department activities as assigned.
Requirements:
  • Clear and Active State of FL LPN or RN licensure.
  • 2+ years of utilization review/management experience within a MCO processing prior auths for medical necessity.
  • 1+ year experience in clinical hospital discharge planning.
  • Must have a ASN and 4 years of clinical experience or BSN with 2 years of clinical experience.
  • Knowledge regarding community and post-acute resources and related requirements.
  • Experience working with InterQual/Milliman Criteria, Florida Medicaid Program and CMS Guidelines.
Benefits:
  • Immediate enrollment in Health Insurance.
  • Dental Insurance.
  • Life Insurance.
  • Employee Assistance Program (EAP).
  • Access to Investment Accounts.
  • Career and educational tools within our Ingenovis ACT (Advocacy) Program.
Pay Details:

$35/hour - $35/hour



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