Utilization Management Nurse

CenterWell

1d • Remote

About The Position

The Utilization Management RN will collaborate with other health care givers in reviewing medical care and services. This review will involve evaluating actual and proposed care against established CMS Coverage Guidelines/NCQA review criteria. You will be part of a team that focuses on excellent service to others. You will report to a Utilization RN Manager. Use your skills to make an impact.

Requirements

• Active and unrestricted RN license with no disciplinary action
• 5+ years of clinical RN experience
• 5+ years of Acute Care experience in the Hospital ICU or ER settings
• Prior clinical experience, managed care experience, DME, Florida Medicaid OR utilization management experience
• Experience cross training and floating among teams
• Available for On Call weekend/holiday rotation
• Self-provided internet service must meet the following criteria: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. Satellite, cellular and microwave connection can be used only if approved by leadership.
• Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.

Nice To Haves

• BSN or bachelor's degree in a related field
• Active and unrestricted Compact Registered Nurse (RN) license with no disciplinary action (including Nevada)
• Experience working within Florida Medicaid
• Experience with Physical Therapy, DME, Cardiac or Orthopedic procedures
• Experience in utilization management within Insurance industry
• Medicare Advantage, Medicare or Medicaid Experience
• Current nursing experience in Hospital, SNF, LTAC, DME or Home Health.
• Bilingual in English and Spanish with the ability to read/write and speak in both languages

Responsibilities

• Collaborate with other health care givers in reviewing medical care and services.
• Evaluate actual and proposed care against established CMS Coverage Guidelines/NCQA review criteria.
• Participate in an On Call weekend/holiday rotation.
• Travel for offsite Orientation for 2 to 8 weeks.
• Travel to offsite meetings up to 6 times a year.

Benefits

• medical
• dental
• vision benefits
• 401(k) retirement savings plan
• time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave)
• short-term and long-term disability
• life insurance

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level