HollywoodFLRecruiter Since 2001
the smart solution for Hollywood jobs

REMOTE Utilization Management Nurse Reviewer - Nurse Practitioner

Company: Max Populi, LLC
Location: Miramar
Posted on: February 23, 2021

Job Description:

View all jobs REMOTE Utilization Management Nurse Reviewer - Nurse Practitioner Miramar, FL -- Healthcare
--
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;--
      Required Experience
      • 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.--
        --
        -- Contact information: ________________________________________________ Recruiter Max Populi, LLC 4628 Bayard Street, #207 Pittsburgh, PA 15213-2750 Tel: (412) 567-5279 Fax: (412) 567-5198 e-mail: jobs @maxpopuli.com Website: http://www.maxpopuli.com

Keywords: Max Populi, LLC, Hollywood , REMOTE Utilization Management Nurse Reviewer - Nurse Practitioner, Executive , Miramar, Florida

Click here to apply!

Didn't find what you're looking for? Search again!

I'm looking for
in category
within


Other Executive Jobs


Sales Director
Description: OUTFRONT Media has an opportunity for an experienced sales leader to motivate a team of account executives with a focus on media integration, client engagement and smart strategies. As the largest Out (more...)
Company: Outfront Media
Location: Miami
Posted on: 03/1/2021

Transportation Sales Manager
Description: br Carrier Sales Manager br br At Cargobot, we are dedicated to supplying the best app and online freight logistics experience along with excellent customer service to the thousands of customers (more...)
Company: Cargobot
Location: Miami
Posted on: 03/1/2021

Chief Financial Officer
Description: Rye Development a developer of new hydropower projects on existing dams is conducting a search for a Chief Financial Officer to join the management team. Rye through its affiliates, has been granted licenses (more...)
Company: Rye Development
Location: West Palm Beach
Posted on: 03/1/2021


Vice President for Institutional Advancement
Description: 'https://maps.googleapis.com/maps/api/js
Company: Gulliver Preparatory School
Location: Miami
Posted on: 03/1/2021

Remote Biotech Clinical Trials Project Leadership Director
Description: A healthcare company is filling a position for a Remote Biotech Clinical Trials Project Leadership
Company: VirtualVocations
Location: Miami
Posted on: 03/1/2021

General Manager
Description: EquipmentShare is Hiring a General Manager. br br EquipmentShare is searching for an experienced General Manager to launch and grow our rental location in Miami, FL. br br About EquipmentShare (more...)
Company: EquipmentShare
Location: Miami
Posted on: 03/1/2021

Sr. Director, Planned Gifts and Endowment
Description: br br br Help us make a difference in our community. United, we are tackling complex issues and turning contribution into real change. Join our team and join us in the fight for a stronger Miami (more...)
Company: United Way Of Miami-Dade Inc
Location: Miami
Posted on: 03/1/2021

Director of Brand Expansion
Description: Director of Brand Expansion br Location: Remote br br Who You'll Work For br br REEF's mission is to connect the world to your block. br br We transform underutilized urban spaces into neighborhood (more...)
Company: REEF
Location: Miami
Posted on: 03/1/2021

IFS Project Manager
Description: Manages the site specific IFS Implementation Stream and interface between the back-office governance team
Company: Chestnut Hill Technologies
Location: Miami
Posted on: 03/1/2021

Management Training
Description: Management TraineeAll candidates must be well spoken and able to present a professional manner. Our employment opportunities offer cross training in the business development fields of customer service (more...)
Company: The Linum Group
Location: Miami
Posted on: 03/1/2021

Log In or Create An Account

Get the latest Florida jobs by following @recnetFL on Twitter!

Hollywood RSS job feeds