Cigna Doral , FL 33166
Job Title: Bilingual Utilization Review Nurse
To review requests for coverage of outpatient and inpatient medical services, request additional clinical information as needed, review applicable coverage guidelines, approve services that meet established criteria or forward requests to medical director for secondary review.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
1.Review requests for medical services that require prior authorization as per LMCHP/Medicare guidelines and timeframes, including both outpatient and inpatient services.
2.Contact requesting providers to obtain additional information when needed to establish medical necessity.
3.Might conduct on-site concurrent reviews at inpatient hospitals/units, to establish medical necessity of services being rendered.
4.Approve requests that fulfill LMCHP and Medicare coverage guidelines or forwards cases that require additional review to Medical Director
5.Answer telephonic inquiries from medical directors and providers regarding the status of organization determinations.
6.Maintain open channels of communication with requesting providers, attending physicians and business partners.
7.Comply with Leon Medical Centers Health Plans, Medicare and State policies and procedures and maintain confidentiality of member information in accordance with state and federal laws.
8.Participate in mandatory trainings and competency testing as required.
9.Maintain up-to-date clinical knowledge.
10.Perform other related duties assigned.
Registered Nurse with unrestricted Florida License
2 or more years of experience in a clinical setting
Fluency in spoken and written Spanish
One or more years of experience in utilization review
Extensive knowledge of Medicare guidelines
Bachelor's level education