Our client is an integrated homecare service provider focused on meeting the needs of Health Plans by serving their members through a single source solution. We engage in risk based (e.g. capitation, shared savings) deals with health plans and other risk bearing groups to provide home health, DME, and home infusion services at low cost and high quality. Our delivery model has served over one million health plan members nationwide, contributing to higher star rankings and lower healthcare costs.
We are hiring several Utilization Management Nurse Reviewers in our Miramar, FL office. These positions will have flexibility to work remote after initial onsite onboarding. The utilization management Nurse performs prospective, concurrent and reviews for home care services, durable medical equipment and ancillary services. The purpose and goals of utilization management are to assure that the patients receive medically necessary care at the appropriate place, with the appropriate provider, and at the appropriate level of care.
This position is responsible for timely review of request for services and based on established clinical guidelines and/or coverage benefits limitations, determine appropriateness of requested services.
Complies with all standard operating procedures, and all departmental and organizational policies. Meets and exceeds minimum benchmark established for the role. Develops relationships with physicians, healthcare service providers, and internal and external customers to help improve health outcomes for enrollees. Applies clinical knowledge to work with facilities and providers for care coordination.
Accesses and consults with peer clinical reviewers, Medical Directors, and/or delegated clinical reviewers to help ensure medically appropriate, quality, cost effective care throughout the medical management process.
Essential Job Functions
- Adheres with HIPAA regulation and departmental policies and procedures.
- Accurate interpretation of established clinical guidelines.
- Adhere and perform timely prospective review for services requiring prior authorization.
- Adhere and perform timely concurrent review for on-going home care services, durable medical equipment and ancillary services.
- Perform timely retrospective review for services that required prior authorization but was not obtained by the provider.
- Refers treatment plan(s)/plan of care to peer clinical reviewers in accordance with established criteria/guidelines and follows process for second level review. (Nurse does not issue medical necessity non-certifications).
- Keep abreast of health care benefits and limitations, regulatory requirements, disease processes and treatment modalities, community standards of patient care, and professional nursing standards of practice.
- Notifies the member and/or provider by phone, fax, e-mail or letter per protocol.
- Able to manage multiple tasks, be detail oriented, be responsive, and demonstrate independent thought and critical thinking.
The ideal candidate will determine
- Eligibility confirmation;
- Benefit level verification for limitations/exclusions;
- Coordinates care and benefits across settings and providers for certain services;
- Appropriate physician documentation of referrals;
- Required information for processing; contacts provider(s) to obtain the necessary information to make a coverage determination;
- Sorts requests by urgency of applicable turnaround time criteria (TAT);
- Ability to analyze medical documentation and apply criteria to determine medical necessity, acuity of care, severity of illness and intensity of service;
- Authorizes requests that meet the eligibility, benefit coverage, and medical necessity criteria;
- Minimum of 1-2(+) years of clinical or utilization review experience, case management, managed care regulations required.
- Track record of progressively increasing levels of management responsibilities with a focus on performance of a variety of utilization functions including conducting inter-rater reliability quality audits.
- Understanding of managed care guidelines and impact on services. Pre-authorization or Concurrent Review experience.
- Licensed Nurse Practitioner
- Pre-authorization or Concurrent Review experience.
- Good computer skills with accurate data entry into an electronic health record.
- Knowledge of Medicare, Medicaid coverage criteria (i.e. Milliman Care Guide, InterQual), Home Health criteria, Durable Medical Equipment (DME).
- Knowledge of State and Federal regulations regarding Utilization Management and accreditation standards
- Bilingual (Spanish/English) preferred.