{"id":2089,"date":"2016-08-10T16:06:29","date_gmt":"2016-08-10T16:06:29","guid":{"rendered":"http:\/\/nexushc.com\/?p=2089"},"modified":"2016-10-05T20:15:42","modified_gmt":"2016-10-05T20:15:42","slug":"lead-utilization-management-rn-fl","status":"publish","type":"post","link":"http:\/\/nexushc.com\/?p=2089","title":{"rendered":"Lead Utilization Management \u2013 RN (FL)"},"content":{"rendered":"

Miami, FL; Remote possibility from Miami area<\/span><\/p>\n

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.<\/p>\n

\u2022 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.
\n\u2022 Mentors and trains UM staff. Serves as a \u201cbuddy\u201d 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.
\n\u2022 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.
\n\u2022 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.
\n\u2022 Develops and implements transition plans, as indicated, to ensure continuity of care. Negotiates and documents single case agreements according to the company’s procedures.
\n\u2022 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.
\n\u2022 Collaborates with the Care Coordination Team to implement support for transitions in care. Facilitates timely sharing of enrollees\u2019 clinical information (such as previous treatment, medications, and planned care) in order to promote continuity of care.
\n\u2022 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.
\n\u2022 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.
\n\u2022 Participates in Care Coordination Team and utilization management activities, including collaboration with other staff on enrollee cases, and performing data collection, tracking, and analysis.
\n\u2022 Maintains an active work load in accordance with performance standards.
\n\u2022 Advocates for the enrollee to ensure health care needs are met; Interacts with providers in a professional, respectful manner.
\n\u2022 Provides coverage of Nurse Line and\/or Crisis Line as requested or required for position.<\/p>\n

Requirements<\/strong><\/p>\n

\u2022 Prefer recent Florida Medicaid experience
\n\u2022 Requires minimum of 5 years of experience conducting utilization management according to medical necessity criteria.
\n\u2022 Registered Nurse, FL Licensure required
\n\u2022 Certified Case Manager preferred
\n\u2022 Knowledge of medical utilization management procedures, Medicaid benefits, community resources and providers. Knowledge and experience in diverse patient care settings including inpatient care.
\n\u2022 Ability to function independently and as a team member.
\n\u2022 Knowledge of ICD and DSM IV coding or most current edition.
\n\u2022 Ability to analyze specific utilization problems and creatively plan and implement solutions.
\n\u2022 Able to demonstrate the ability to quickly develop an alliance with providers via telephone.<\/p>\n

Apply Now<\/span><\/a><\/p>\n

Not sure if you want to apply?
\nContact us for more info:
\nRebecka Boyd
\n804-502-0870
\n nexusexecutivesearch@gmail.com<\/a><\/span><\/p>\n