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.
Their 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 South Florida.
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.
- 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.
- Applies clinical knowledge to work with facilities and providers for care coordination.
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.
· 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.
· Coordinate care and benefits across settings and providers for certain services.
· Required information for processing; contacts provider(s) to obtain the necessary information to make a coverage determination.
· Medical documentation and apply criteria to determine medical necessity, acuity of care, severity of illness and intensity of service.
· Authorization of requests that meet the eligibility, benefit coverage, and medical necessity criteria;
- Minimum of 1-2(+) years of clinical or utilization review experience, case management
- Health Plan experience required
- Experience in Utilization review required.
- Background in home health is a plus.
- Understanding of managed care guidelines and impact on services. Pre-authorization or Concurrent Review experience.
- Bachelor's degree in Nursing
- Active Registered Nurse license in Florida.
- Pre-authorization or Concurrent Review experience necessary.
- 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 CMS regulations regarding Utilization Management and accreditation standards
- Bilingual (Spanish/English) preferred not required.