Utilization Management Nurse RN/LPN
About The Position
The Utilization Management Nurse (UMN) works under general supervision of the Director and/or Manager/Supervisor of Medical Management and in collaboration with the interdisciplinary team. The role reviews service authorization requests to support appropriate utilization of services, including selected specialties, medical treatments and services, elective hospital admissions, rehabilitative and ancillary services, home care, and out-of-plan referrals. The UMN assists with complex cases and internal process development, and works closely with Medical Directors and other Medical Management staff to guide appropriate utilization and data capture. The UMN educates physicians and other team members on utilization review issues, including inappropriate admissions and placements. The role also manages continuity of care, supports safe transitions, promotes provider and patient satisfaction and patient safety, and ensures appropriate length of stay. Community Care Plan currently follows a hybrid work schedule and reserves the right to change work schedules based on company needs. The role may involve work inside and outside the office, travel to other offices, and domestic travel. A Level 2 background screening through Florida’s Care Provider Background Screening Clearinghouse is required for selected candidates.
Requirements
- Current unrestricted Florida RN or LPN license.
- Four years of related clinical experience in a healthcare field, or an equivalent combination of education and experience.
- Knowledge of case management and utilization review concepts, including InterQual and Milliman Criteria, the Florida Medicaid Program, and CMS Guidelines.
- Knowledge of community and post-acute resources and related requirements.
- Proficiency with word processing software, spreadsheet software such as Microsoft Excel, and electronic medical record software.
- Superior clinical skills to determine appropriate clinical and other information for medical necessity reviews and identify appropriate mechanisms to address delays or variation from expected care practices.
- Critical-thinking and problem-solving skills.
- Ability to work in a fast-paced environment, work independently, make decisions, and adapt to changing priorities.
- Professionalism and ability to communicate effectively with diverse populations.
- Ability to maintain confidentiality.
- Ability to work some weekends and holidays when required.
- Valid Florida Driver’s License.
Nice To Haves
- At least two years of utilization review experience.
- At least one year of discharge-planning experience in an acute care setting.
Responsibilities
- Review prior authorization requests for medical necessity and appropriateness using standardized review criteria, and coordinate with the Medical Director or physicians on requests outside standard criteria.
- Maintain compliance with federal and state guidelines and contractual requirements, coordinating with the Medical Director to ensure timely processing.
- Obtain necessary documentation, address discrepancies, and follow up until assigned cases reach a determination.
- Liaise between the Medical Director, physicians, and office staff to resolve prior authorization questions, issues, and problems; communicate denial determinations to providers when indicated.
- Evaluate and concurrently monitor appropriate resource utilization, including durable medical equipment, hospitalizations, home healthcare, infusion services, and long-term rehabilitation.
- Maintain current and timely documentation reflecting department work processes and policy guidelines.
- Promote safe and appropriate coordination of care.
- Promote, facilitate, and control optimal resource utilization consistent with organizational goals.
- Identify and participate in developing programs, policies, and procedures that promote continuous quality improvement.
- Ensure adherence to company and department confidentiality policies and procedures.
- Participate in regular departmental training.
- Coordinate enrollee benefits with providers and/or external organizations as a plan liaison.
- Prepare and present reports on department activities as assigned.
- Perform other job-related duties assigned by a supervisor or management.
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What This Job Offers
Job Type
Full-time
Education Level
No Education Listed
