Job Description

Position Summary:

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 primary responsibilities are to perform the review of requests for service authorizations in order to assist with utilization of appropriate services. These reviews include but are not limited to 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 interacts closely with the Medical Directors and other Medical Management staff to direct appropriate utilization and data capture. The UMN will provide education to physicians and other members of the team on the issues related to utilization review including inappropriate admissions and placements. The UMN is also responsible for managing continuity of care, ensuring smooth and safe transitions, provider and patient satisfaction, patient safety and appropriate length of stay.

Essential Duties and Responsibilities:

1. 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.
2. 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.
3. Obtains necessary documentation and ensures completion of assigned caseload by addressing discrepancies and following up until a determination is achieved.
4. 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
5. 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.
6. Provides current and timely documentation reflecting department work processes and policy guidelines.
7. Promotes safe and appropriate coordination of care.
8. Promotes, facilitates, and controls the optimal utilization of resources, consistent with organizational goals.
9. Identifies and participates in the development of programs, policies, and procedures to promote continuous quality improvement.
10. Assures adherence to company and department policies and procedures regarding confidentiality.
11. Participates in regular departmental training.
12. Serves as a plan liaison to coordinate enrollee benefits with providers and /or external organizations.
13. Prepares and presents reports on department activities as assigned.

This job description in no way states or implies that these are the only duties performed by the employee occupying this position. Employees will be required to perform any other job-related duties assigned by their supervisor or management.

Skills and Abilities:

• Superior clinical skills to determine appropriate clinical and other information for medical necessity reviews and identify appropriate mechanism to address delays or variation for expected care practices.
• Critical thinking and problem-solving skills.
• Ability to work in a fast-paced environment.
• Ability to be self-directed and work independently with decision making skills.
• Ability to demonstrate flexibility with changing priorities.
• Professionalism.
• Ability to communicate effectively with diverse populations.
• Ability to always maintain confidentiality.
• Ability to work some weekends and holidays, when required.

Work Schedule:

As a continued effort to provide a safe and productive work environment, Community Care Plan is currently following a hybrid work schedule. Staff are able to work from home 3 days a week and will report to the office 2 days a week. *****The company reserves the right to change the work schedules based on the company needs.

Physical Demands:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to sit, use hands, reach with hands and arms, and talk or hear. The employee is frequently required to stand, walk, and sit. The employee is occasionally required to stoop, kneel, crouch or crawl. The employee may occasionally lift and/or move up to 15 pounds.

Work Environment:

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of the job. The environment includes work inside/outside the office, travel to other offices, as well as domestic, travel. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The noise level in the work environment is usually moderate.

We are an equal opportunity employer who recruits, employs, trains, compensates and promotes regardless of age, color, disability, ethnicity, family or marital status, gender identity or expression, language, national origin, physical and mental ability, political affiliation, race, religion, sexual orientation, socio-economic status, veteran status, and other characteristics that make our employees unique. We are committed to fostering, cultivating and preserving a culture of diversity, equity and inclusion.

Qualifications

• Current unrestricted Florida RN or LPN License.
• Minimum of two years of utilization review/case management experience and a minimum of one year of experience in discharge planning in an acute care setting highly desirable.
• Four years related clinical experience in a healthcare field; or equivalent combination of education and experience.
• Valid Florida Driver’s License.
• Knowledge of case management and utilization review concepts, including InterQual and Milliman Criteria, Florida Medicaid Program and CMS Guidelines.
• Knowledgeable regarding community and post-acute resources and related requirements.
• Proficient in word processing software, spreadsheet software such as Microsoft Excel, and electronic medical record software.

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