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Utilization Review Quality Manager

Miramar, FL · Healthcare
We are searching for an experienced Utilization Review Nurse with Quality Assurance background to drive audits and compliance projects for a rapidly growing integrated healthcare organization in South Florida.
Our client is a private equity backed organization that uses evidence-based medicine to meet the needs of Health Plans by serving their members through a single source solution.
This opportunity is to perform quality oversight for the UM program. This is a fast track to a Director role.
Responsibilities include -
  • Ensure that the UM processes and delegation expectations are synchronized and maintained with appropriate and timely and quality of care and services.
  • Facilitate continuous improvement in UM and ancillary services through collaboration with process owners.
  • Maintain analytical systems to assess, monitor and improve performance of required components.
  • Ensure departmental and intra-departmental compliance with regulatory and accreditation agency.
  • Assess the strategies of UM processes to determine types of monitoring tools and outcomes; ensure compliance with the quality measures, and supports strategies for improvement within the UM scope.
  • Achieve and maintain compliance with federal, state and NCQA requirements and guidelines including maintenance of corrective action plan (CAP), monitoring CAP activities and providing education and tools as indicated. Assist in completion and collection of required reports timely, and analyzing the data to facilitate compliance with processes.
  • Monitor compliance with provider organization quality background investigation and report to Credentialing Committee.
  • Develop Policies and Procedures related to delegation oversight process.
  • Oversee regulatory audits, including preparation and monitoring of any corrective action plans.
  • Maintain professional and technical knowledge by attending educational workshops; reviewing professional publications, and completing all requirements for ongoing licensures and certifications.
Ideal candidate
  • Valid, unrestricted Registered Nurse (R.N.) license.
  • 3-5 years of acute care clinical nursing experience.
  • At least one year’s experience with Quality Improvement
  • Familiarization with InterQual and/or Milliman, CMS and peer reviewed guidelines for appropriateness of care and medical necessity determinations.
  • Health plan experience preferred.
  • Intermediate computer skills, at a minimum, proficient in MS Office Suite of Programs.
  • Possess communication, conflict resolution, negotiating and interpersonal skills.
  • Must be able to prioritize, plan, and handle multiple tasks/demands simultaneously.
COVID-19 considerations:
We have undertaken extraordinary measures to keep our employees safe during these times. Face masks required, six feet distance necessary, sanitized work space.
Contact information:
Max Populi, LLC
4628 Bayard Street, #207
Pittsburgh, PA 15213-2750
Tel: (412) 567-5279
Fax: (412) 567-5198
e-mail: jobs@maxpopuli.com
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