Utilization Management Nurse

Solis Health Plans

7d • Onsite

About The Position

Under the supervision of the Health Services Director, the Utilization Management Nurse (LPN or RN) uses a multidisciplinary approach to organize, coordinate, monitor, evaluate, create and manage organization determinations and authorizations. These service requests will focus on selected complex medical and psychosocial needs of Solis Health Plans members. The UM Nurse is responsible for assuring the receipt of high quality, cost efficient medical outcomes for enrollees. This role works with Medical Directors, Authorization Coordinators and Service Coordinators to perform first level review to pre-certify elective services, procedures and tests utilizing established Care Coordination polices and protocols, Solis Health Plans benefit criteria, applicable regulatory review criteria and nationally accepted criteria for medical necessity determination.

Requirements

• Graduate from an accredited school of nursing, or Bachelors (or advanced) degree in nursing.
• Active and unrestricted licensure as a Registered Nurse in Florida.
• A minimum of three to five years clinical experience as a Registered Nurse in a clinical setting required.
• 2 years’ experience as a Utilization Management nurse in a managed care payer preferred.
• One year experience as a case manager in a payer or facility setting highly preferred.
• Discharge planning experience highly preferred.
• Bilingual in English and Spanish is required

Responsibilities

• Conduct concurrent and retrospective utilization review for inpatient, observation or SNF services.
• Conducts clinical reviews of proposed services against appropriate criteria/guidelines to determine medical necessity, benefit eligibility, and network contract status.
• Work with Medical Directors, Program Leadership and Solis Health Plans Provider Relations Teams to identify and mitigate facility barriers associated with the ability to make timely decisions.
• Identify, align and utilize health plan and community resources that impact high-risk/high cost care.
• Act as liaison between assigned facilities, members/families, and Solis Health Plans. Clarify policies/procedures and member benefits as needed. Authorizes services, coordinates care, and ensures timeliness and coordination of healthcare services, in compliance with department and regulatory standards, seeking supplemental services when appropriate or when needed.
• Assess enrollee needs and monitor progress toward goals at all times, communicating findings and status with members of the enrollee’s primary care team.
• Ensure optimal delivery of safe quality health care to members, while maximizing resources and containing costs, and facilitate continual patient-centered and outcome-driven health performance improvement activities.
• Review enrollees with the Medical Directors and Primary Care Teams and advocates for Administration Exception considerations as appropriate.
• Facilitate communications between the facility, providers, and the PCT in order to effect and influence a safe and effective discharge plan and care plan for the enrollee.

Benefits

• Full benefits package offered on the first on the month following date of hire including: Medical, Dental, Vision, 401K plan with a 100% company match!

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 11-50 employees