Utilization Management Nurse -Hybrid

Utilization Management Nurse-Hybrid

HealthCare Support is actively seeking a Utilization Management Nurse-Hybrid to fill an opening with a Health Plan in Sunrise, FL.

Daily Responsibilities for Utilization Management Nurse-Hybrid:

• Reviews prior authorization requests for medical necessity and appropriateness, utilizing standardized Review Criteria; Coordinates with the Medical Director/Physicians for those requests outside of standard Review Criteria.
• Maintains compliance with federal and state guidelines as well as contractual requirements as determined by line of business; this includes coordinating with the Medical Director to ensure requests are processed timely.
• Obtains necessary documentation and ensures completion of assigned caseload by addressing discrepancies and following up until a determination is achieved.
• Serves as a liaison between the Medical Director, physicians and office staff in resolving prior authorization questions, issues and problems; communicates denial determinations to providers when indicated
• Performs evaluation and concurrent monitoring of appropriate utilization of resources including but not limited to durable medical equipment, hospitalizations, home healthcare, infusion services and long term rehabilitation.
• Provides current and timely documentation reflecting department work processes and policy guidelines.
• Promotes safe and appropriate coordination of care.
• Promotes, facilitates, and controls the optimal utilization of resources, consistent with organizational goals.
• Identifies and participates in the development of programs, policies, and procedures to promote continuous quality improvement.
• Assures adherence to company and department policies and procedures regarding confidentiality.
• Participates in regular departmental training.
• Serves as a plan liaison to coordinate enrollee benefits with providers and /or external organizations.
• Prepares and presents reports on department activities as assigned.
• Shift: Mon- Fri between 8am- 5pm
• HYBRID position

Required Qualifications for Utilization Management Nurse-Hybrid:

• Clear and Active State of FL LPN or RN licensure
• 2+ years of utilization review/management experience withing a MCO processing prior auths for medical necessity
• 1+ year experience in clinical hospital discharge planning
• Must have a ASN and 4 years of clinical experience or BSN with 2 years of clinical experience
• Knowledge regarding community and post-acute resources and related requirements
• Experience working with InterQual/Milliman Criteria, Florida Medicaid Program and CMS Guidelines.
• Strong computer skills: MS Suite and EMR systems
• Valid and active FL driver’s license
• Ability to work from home

Preferred Qualifications for Utilization Management Nurse-Hybrid:

• RN Highly preferred

Benefits for Utilization Management Nurse-Hybrid:

• Immediate enrollment in Health Insurance

• Dental Insurance
• Life Insurance
• Employee Assistance Program (EAP)
• Access to Investment Accounts
• Career and educational tools within our Ingenovis ACT (Advocacy) Program

Pay Details: $35/hour – $35/hour

Interested in being considered?
If you are interested in applying to this position, please click Apply Now for immediate consideration.

For additional consideration, please email a copy of your resume to karla.roque@healthcaresupport.com with your phone number, the job title and location, and our recruiters will reach out.
Healthcare Support Staffing, LLC is an equal employment opportunity employer and will consider all qualified applicants without regard to race, color, religion, disability, sex, sexual orientation, gender identity, national origin, protected veteran status, or any other characteristic protected by applicable local, state, or federal law.

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