Utilization Review Nurse

SECUR Health Plan • Tampa, FL

2d • Onsite

About The Position

The Utilization Review Nurse performs care management duties to assess, plan and coordinate all aspects of medical and supporting services across the continuum of care for select members to promote quality, cost effective care.

Requirements

• Bachelor’s degree in nursing or related field or an equivalent combination of work experience and education
• Current license as RN or LPN, current active single-state out-of-state nurse license, or current active multistate/compact nurse license
• Minimum 2 years of clinical nursing experience in a managed care, clinical, acute care, or community setting
• Demonstrated knowledge of payor contracts and able to provide clinical information to Physicians to ensure cost effective care and metrics standards
• Previous experience working with an EMR/EHR (Electronic Medical/Health Record) system
• Proficient Microsoft Office Suite skills
• Ability to convey empathy and compassion in emotionally charged situations
• Ability to effectively communicate in English (verbal and written)

Nice To Haves

• CCM or other case management certification preferred

Responsibilities

• Perform standard, retrospective, and/or concurrent reviews of authorization requests submitted by in-network and out-of-network providers
• Perform discharge planning assessment and coordination of subacute care services and benefit enhancements
• Assess the member's current health status, resource utilization, past and present treatment plan and services, prognosis, short- and long-term goals, treatment and provider options; coordinate and conduct utilization management activities
• Coordinate services between Primary Care Physician (PCP), specialists, medical providers, and non-medical staff to meet the complete medical socio-economic needs of clients; enter and maintain assessments, authorizations, and pertinent clinical information into various medical management systems
• Provide education to patients and providers
• Facilitate member access to community-based services
• Provide relevant data for Utilization Management Committee Meetings, attend and participate as required
• Identify related risk management quality concerns and reports these scenarios to the appropriate resources
• Performs other duties as assigned

What This Job Offers

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