Sorry, this job is no longer accepting applications. See below for more jobs that match what you’re looking for!

Utilization Review Nurse

Expired Job

Carenational Tampa , FL 33607

Posted 2 months ago

Utilization Review Nurse (RN or LPN) - Managed Care
Tampa, FL
This is a full-time, benefits available, CONTRACT opportunity, expected to last 3 months, or longer!

Utilization
Review Nurse

Job Summary:

  • The Utilization Review Nurse is responsible for utilization management and utilization review for prospective (prior authorization), concurrent, or retrospective review.
  • The Utilization Review Nurse will performs reviews of services, and determine medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination.
  • Utilize clinical skills to telephonically provide and facilitate utilization review, continued stay reviews and utilization management of all cases based on clinical experience and recognized guidelines.
  • The Utilization Review Nurse will obtain the information necessary to assess a member's clinical condition, identify ongoing clinical care needs and ensure that members receive services in the most optimal setting to effectively meet their needs.
Utilization Review Nurse Background:
  • Current, valid, and unrestricted state Registered Nurse (R.N.) or License Practical Nurse (L.P.N.) license.
  • CCM or CPUR or similar certification is preferred
  • 2 years acute care clinical nursing experience is required.
  • 1 year of recent experience in Utilization Review or Utilization Management at a health plan or other managed care organization (HMO/TPA/IPA/etc).
  • Knowledge of guidelines for Medicaid/Medicare and related state programs is required.
  • Experience using Milliman or InterQual criteria for medical necessity, setting and level of care, and concurrent patient management.
  • Computer skills to include Microsoft Word, Excel, database use, and basic data entry.
#CLINICAL
See if you are a match!

See how well your resume matches up to this job - upload your resume now.

Find your dream job anywhere
with the LiveCareer app.
Download the
LiveCareer app and find
your dream job anywhere
lc_ad

Boost your job search productivity with our
free Chrome Extension!

lc_apply_tool GET EXTENSION

Similar Jobs

Want to see jobs matched to your resume? Upload One Now! Remove
Licensed Utilization Review II (Call Center Nurse) Tampa FL 2/11/19 Start Date Ps16054

Anthem, Inc.

Posted 5 days ago

VIEW JOBS 12/13/2018 12:00:00 AM 2019-03-13T00:00 Your Talent. Our Vision. At Amerigroup, a proud member of the Anthem, Inc. family of companies focused on serving Medicaid, Medicare and uninsured individuals, it's a powerful combination. It's the foundation upon which we're creating greater care for our members, greater value for our customers and greater health for our communities. Join us and together we will drive the future of health care. This is an exceptional opportunity to do innovative work that means more to you and those we serve. Licensed Utilization Review II (Call Center Nurse) Medicaid- 2/11/19 start date This position is responsible for working primarily with healthcare providers to help ensure appropriate and consistent administration of plan benefits through collecting clinical information required to preauthorize services, assess medical necessity, out of network services, and appropriateness of treatment setting and applying appropriate medical policies, clinical guidelines, plan benefits, and/or scripted algorithms within scope of licensure. This level works with more complex elements and requires review of more complex benefit plans. May also serve as a resource to less experienced staff. Examples of such functions may include: review of claim edits, pre-noted inpatient admissions or, episodic outpatient therapy such as physical therapy that is not associated with a continuum of care, radiology review, or other such review processes that require an understanding of terminology and disease processes and the application of clinical guidelines but do not require nursing judgment. Primary duties may include, but are not limited to: * Conducts pre-certification, inpatient, retrospective, out of network and appropriateness of treatment setting reviews within scope of licensure by utilizing appropriate medical policies and clinical guidelines in compliance with department guidelines and consistentwith the member's eligibility, benefits and contract. * Develops relationships with physicians, healthcare service providers, and internal and external customers to help improve health outcomes for members. * Applies clinical knowledge to work with facilities and providers for care-coordination. * May access and consult 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. * Educates the member about plan benefits and contracted physicians, facilities and healthcare providers. * Refers treatment plans/plan of care to peer clinical reviewers in accordance with established criteria/guidelines and does not issue medical necessity non-certifications. * Facilitates accreditation by knowing, understanding, and accurately applying accrediting and regulatory requirements and standards. * Requires an RN, LPN, or LVN; 2 years of clinical or utilization review experience. * 1 year of managed care experience and knowledge of the medical management process; or any combination of education and experience which would provide an equivalent background. * Current unrestricted RN, LPN, or LVN license in Florida is required. * Must be able to commit to 100% attendance for first 90 days. * Must be able to work any hours of operation from 7AM-7PM . * Must have experience with electronic documentation. * Must having experience using Microsoft Outlook. * Ability to obtain license in other states is preferred. Anthem, Inc. is ranked as one of America's Most Admired Companies among health insurers by Fortune magazine and is a 2018 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company and apply, please visit us at antheminc.com/careers. An Equal Opportunity Employer/Disability/Veteran. Anthem, Inc. Tampa FL

Utilization Review Nurse

Expired Job

Carenational