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SalaryAvMed, a division of Sentara Health Plans in the Florida market, is hiring a Utilization Review Nurse Coordinator Miami, Florida. This is a hybrid position, 2 days in office and 3 days remote.
Scope of position: The Utilization Review Nurse provides Member medical utilization management by utilizing nursing clinical assessment skills, approved medical necessity clinical criteria and benefit criteria to review authorization requests for appropriateness of medical treatment in the appropriate medical setting during the appropriate timeframe.
Essential Job Functions:
- Conducts reviews for all requests based on medical appropriateness established by nationally accredited guidelines and internal procedures; Initiates second level reviews when submitted documentation fails to satisfy established guidelines and procedures.
- Maintains an enhanced level of regulatory knowledge requirements for the authorization process; employs the ability to identify, prevent and escalate potential compliance issues. Participates in regulatory compliance audits.
- Exhibits superior written and verbal communication skill set to allow collaboration with department, AvMed, Providers, Members and compliance requirements.
- Offers the Provider/Member options and alternatives to requested services within clinical guidelines, benefits and established criteria to ensure that the Member receives the appropriate treatment, in the appropriate setting for the appropriate length of stay.
- Provides oversight of non-clinical team associates.
- Identifies potential problem areas of excessive utilization, and/or inefficient care delivery.
- Assists Members with transition of care/continuation of care benefit coverage with new enrollment or when Provider terminates from AvMed network.
- Functions as a liaison to promote an effective working relationship between AvMed’s providers, hospitals, contracted health care agencies and the member/caregiver.
- Ability and willingness to serve as a Subject Matter Expert (SME) in at least one specialty area within the Clinical Coordination Department.
- Performs additional duties and responsibilities as assigned by management.
Minimum Requirements:
- Associates required
- Bachelors preferred
- Registered Nurse with an active and unrestricted FL license
- LPN with an active and unrestricted FL license with 5-10 years of health plan experience considered
- 3-5 years of years of Clinical nursing experience and/or managed care, discharge planning or Utilization Review including clinical chart review experience; hospital clinical experience preferred
- Certified Case Manager (CCM) or American Case Management Certification (ACM) preferred
Preferred Requirements:
- Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), and International Classification of Diseases (ICD9) codes
- Critical Thinking
- Ability to work independently
- Ability to manage multiple project and responsibilities with competing priorities
- Communications and collaboration, internally and externally
- Organizational and prioritization skills
- Bilingual in English and Spanish is a plus but not required.
Our Benefits:
As the third-largest employer in Virginia, Sentara Health was named by Forbes Magazine as one of America's best large employers. We offer a variety of amenities to our employees, including, but not limited to:
- Medical, Dental, and Vision Insurance
- Paid Annual Leave, Sick Leave
- Flexible Spending Accounts
- Retirement funds with matching contribution
- Supplemental insurance policies, including legal, Life Insurance and AD&D among others
- Work Perks program including discounted movie and theme park tickets among other great deals
- Opportunities for further advancement within our organization
Sentara employees strive to make our communities healthier places to live. We're setting the standard for medical excellence within a vibrant, creative, and highly productive workplace. For information about our employee benefits, please visit: Benefits – Sentara (sentaracareers.com)
Join our team! We are committed to quality healthcare, improving health every day, and provide the opportunity for training, development, and growth!
Note: Sentara Healthcare offers employees comprehensive health care and retirement benefits designed with you and your family's well-being in mind. Our benefits packages are designed to change with you by meeting your needs now and anticipating what comes next. You have a variety of options for medical, dental and vision insurance, life insurance, disability, and voluntary benefits as well as Paid Time Off in the form of sick time, vacation time and paid parental leave. Team Members have the opportunity to earn an annual flat amount Bonus payment if established system and employee eligibility criteria is met.
Keywords: Talroo-Health Plan, #INDEED, Registered Nurse, Clinical Review
- Registered Nurse (RN) Single State - Nursing License - Virginia
- Registered Nurse (RN) Single State - Nursing License - North Carolina
- Bachelor's Level Degree
- Acute Care 3 years
- Utilization Management Previous Experience
- Accreditation and Regulatory Previous Experience
- Critical Thinking
- Communication
- Coordination
- Microsoft Office
- Complex Problem Solving
- Service Orientation
- Judgment and Decision Making
