REMOTE Utilization Management Nurse Reviewer - Nurse Practitioner
Company: Max Populi, LLC
Posted on: February 23, 2021
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
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
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
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
- Accurate interpretation of established clinical
- 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
- 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
The ideal candidate will determine
- Eligibility confirmation;
- Benefit level verification for limitations/exclusions;
- Coordinates care and benefits across settings and providers for
- Appropriate physician documentation of referrals;
- Required information for processing; contacts provider(s) to
obtain the necessary information to make a coverage
- Sorts requests by urgency of applicable turnaround time
- 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
- 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
- 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
Keywords: Max Populi, LLC, Hollywood , REMOTE Utilization Management Nurse Reviewer - Nurse Practitioner, Executive , Miramar, Florida
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