Utilization Review Nurse - Palm Beach & Broward (2 positions)

Utilization Review Nurses - Broward AND South & Western Palm Beach CountiesAmerica’s Health Choice Medical Plans, Inc., a Medicare HMO, has immediate openings for a Utilization Review Nurse! One position for South & West Palm Beach AND one position for Broward County!!!UTILIZATION REVIEW NURSE, Job # UR0109This position is responsible for and provides support for all utilization activities and discharge planning, acute care, SNF, HHC and DME. Provides support for all utilization management activities as related to Home Health and DME service, coordinating with physicians, medical personnel, patient and families.
Responsibilities:Perform utilization review activities including on-site evaluations and contacting providers to obtain necessary information.
Evaluate and authorize the medical necessity of services. Assist hospital, skilled nursing facilities and/or primary care providers with coordination of referrals for home health and DME services.Obtain all necessary documents for services. Notify service providers of recommended changes in level of care and/or denials and enter data into systems.
Identify high-risk/high-utilization of services and monitor for appropriate care.
Evaluate each admission for quality of care issues and refer cases to Quality Insurance Department.
Track and monitor treatment for institutionalized members.
Review retrospective claims requesting certification and apply approved criteria.
Provide education to providers on Utilization Management policies and procedures.Attend weekly meetings and after-hours responsibilities as required.
Serve as a member advocate and liaison between member, family, and healthcare professionals.
Qualifications/Requirements:
RN with 3-5 years clinical experience. Minimum of 1-2 years in utilization review/hospitalization management preferred.
Ability to articulate clinical and non-clinical data to personnel of all levels of understanding.
Written communication skills that are accurate, timely, and appropriate level to internal and external staff.
Ability to handle multiple tasks, set priorities, and develop action plans.
Detailed oriented, excellent organizational skills, highly self-motivated, and dependable.
Computer skills (Microsoft Office, Word, Excel) and basic knowledge of mainframe – PC systems, printer, fax machine and multi-line phone system.For immediate consideration, please "apply online" with your resume. Include your resume as part of your e-mail, NOT as an attachment (to maximize legibility).
Please include current salary and salary history. Please include JOB #, Job Title, and Location in your reply by listing in the Subject Line.Equal Opportunity Employer / Drug-Free Workplace.
CareerBuilder Keywords:Managed care, health care, nurse, utilization review, Medicare, RN, HMO, Palm Beach, Broward.
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