Utilization Management Nurse RN/LPN

South Florida Community Care Network•Sunrise, FL

1d•Hybrid

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 requests for service authorizations 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 direct appropriate utilization and data capture. The UMN educates physicians and other team members about utilization review, including inappropriate admissions and placements. The role also manages continuity of care, supports smooth and safe transitions, and promotes provider and patient satisfaction, patient safety, and appropriate length of stay. The position requires a 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, and a valid Florida Driver’s License. A minimum of two years of utilization review experience and at least one year of discharge-planning experience in an acute care setting are highly desirable. The UMN should have knowledge of case management and utilization review concepts, including InterQual and Milliman Criteria, Florida Medicaid Program and CMS Guidelines, community and post-acute resources, and related requirements. Proficiency with word processing, spreadsheet software such as Microsoft Excel, and electronic medical record software is required. The role follows a hybrid work schedule, which the company may change based on business needs. Some weekend and holiday work may be required. The position involves work inside and outside the office, travel to other offices, and domestic travel. Physical activities include sitting, using hands, reaching, talking or hearing, standing, walking, and occasionally stooping, kneeling, crouching, crawling, and lifting or moving up to 15 pounds. A Level 2 background screening through Florida’s Care Provider Background Screening Clearinghouse is required for candidates selected for the position.

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.
Valid Florida Driver’s License.
Knowledge of case management and utilization review concepts, including InterQual and Milliman Criteria.
Knowledge of the Florida Medicaid Program and CMS Guidelines.
Knowledge of community and post-acute resources and related requirements.
Proficiency in 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 and independently, with self-direction and decision-making skills.
Ability to demonstrate flexibility with changing priorities.
Professionalism and ability to communicate effectively with diverse populations.
Ability to maintain confidentiality.
Ability to work some weekends and holidays when required.
Ability to meet the physical demands of the job, with reasonable accommodations as applicable.
Candidates selected for the position must complete a Level 2 background screening through Florida’s Care Provider Background Screening Clearinghouse.

Nice To Haves

Minimum of two years of utilization review experience.
Minimum of 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.
Coordinate with the Medical Director or physicians on requests outside standard review criteria.
Maintain compliance with federal and state guidelines and contractual requirements, coordinating with the Medical Director to ensure timely processing.
Obtain necessary documentation, complete assigned caseload, address discrepancies, and follow up until a determination is achieved.
Serve as a liaison among 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 utilization of resources consistent with organizational goals.
Identify and participate in developing programs, policies, and procedures to promote continuous quality improvement.
Ensure adherence to company and department confidentiality policies and procedures.
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.
Perform other job-related duties assigned by a supervisor or management.