Miami, FL; Remote possibility from Miami area

Gathers and synthesizes clinical information in order to authorize services. Reviews health care services to determine consistency with contract requirements, coverage policies and evidence-based medical necessity criteria. Collects and analyzes utilization information. Assists with program processes for transitions across levels of care including discharge planning and ambulatory follow up activity. Serves as an expert resource on coverage policies, covered benefits, and medical necessity criteria. Mentors new Utilization Management (UM) staff and assists with training.

• Provides point of need support and coaching to UM professionals and other clinical team members in the course of normal operations. Builds UM team members expertise through direct feedback and real-time coaching. Provides clinical, procedural or interpretational assistance.
• Mentors and trains UM staff. Serves as a “buddy” to new UM Professionals during their first few months on the job by providing daily support and feedback, reviewing cases being recommended for approval by other UM nursing staff and aids inp presentation to Medical Director.
• Researches and resolves escalated issues that frontline UM professionals cannot resolve in a timely fashion. As necessary, takes escalated calls or fills-in for the UM team during high-peak periods.
• Works with the workforce planning team to perform data collection and analysis of trends to determine problem areas and strategies for better practices for the UM team.
• Develops and implements transition plans, as indicated, to ensure continuity of care. Negotiates and documents single case agreements according to the company’s procedures.
• Reviews planned, in process, or completed health care services to ensure medical necessity and effectiveness according to evidence-based criteria. Proposes alternatives when the requested services do not meet medical necessity criteria or are outside the contracted network. As assigned and based on credentials, monitors and reviews specialized requests and treatment records such as Treatment Record Forms.
• Collaborates with the Care Coordination Team to implement support for transitions in care. Facilitates timely sharing of enrollees’ clinical information (such as previous treatment, medications, and planned care) in order to promote continuity of care.
• Provides information to enrollees, providers, and internal staff regarding covered and non-covered benefits, community resources, agency programs, and company policies and procedures and criteria.
• Interacts with Medical Directors and Physician Advisors to provide case information and discuss clinical and authorization questions and concerns regarding specific cases. Assures that case documentation for each decision is complete, including related correspondence.
• Participates in Care Coordination Team and utilization management activities, including collaboration with other staff on enrollee cases, and performing data collection, tracking, and analysis.
• Maintains an active work load in accordance with performance standards.
• Advocates for the enrollee to ensure health care needs are met; Interacts with providers in a professional, respectful manner.
• Provides coverage of Nurse Line and/or Crisis Line as requested or required for position.


• Prefer recent Florida Medicaid experience
• Requires minimum of 5 years of experience conducting utilization management according to medical necessity criteria.
• Registered Nurse, FL Licensure required
• Certified Case Manager preferred
• Knowledge of medical utilization management procedures, Medicaid benefits, community resources and providers. Knowledge and experience in diverse patient care settings including inpatient care.
• Ability to function independently and as a team member.
• Knowledge of ICD and DSM IV coding or most current edition.
• Ability to analyze specific utilization problems and creatively plan and implement solutions.
• Able to demonstrate the ability to quickly develop an alliance with providers via telephone.

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Contact us for more info:
Rebecka Boyd