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Under general supervision, and in collaboration with Medical Directors and other members of the clinical team, gathers and synthesizes clinical information in order to authorize services. Reviews health care services to determine consistency with contract requirements, coverage policies and evidence-based medical necessity criteria; collects and analyzes utilization information; assists with program processes for transitions across levels of care including discharge planning and ambulatory follow up activity. Serves as an expert resource on coverage policies, covered benefits, and medical necessity criteria.
- Develops and manages new enrollee transitions and those involving a change in provider relationships. Develops and implements transition plans, as indicated, to ensure continuity of care. Negotiates and documents single case agreements according to the company's procedures.
- Reviews planned, in process, or completed health care services to ensure medical necessity and effectiveness according to evidence-based criteria. Proposes alternatives when the requested services do not meet medical necessity criteria or are outside the contracted network. As assigned and based on credentials, monitors and reviews specialized requests and treatment records such as Treatment Record Forms.
- In conjunction with providers and facilities, identifies, develops and monitors discharge plans. Collaborates with the Care Coordination Team to implement support for transitions in care. Facilitates timely sharing of enrollees? clinical information (such as previous treatment, medications, and planned care) in order to promote continuity of care.
- Provides information to enrollees, providers, and internal staff regarding covered and non-covered benefits, community resources, agency programs, and company policies and procedures and criteria.
- Interacts with Medical Directors and Physician Advisors to provide case information and discuss clinical and authorization questions and concerns regarding specific cases. Assures that case documentation for each decision is complete, including related correspondence.
Resources are required to work onsite in Miami, FL.
4 month contract with strong possibility to go permanent
Requirement to work 1-2 weekends per month, but will get one weekday off work in exchange
-RN in the state of Florida
-Bachelor's or Master's Level of Education Required
3 years' experience post degree in a clinical, psychiatric and/or substance abuse health care setting.
Also requires minimum of 3 years of experience conducting utilization management according to medical necessity criteria.
-Ability to use computer systems.
-Good organization, time management and verbal and written communication skills.
-Knowledge of utilization management procedures, Medicaid benefits, community resources and providers
.-Knowledge and experience in diverse patient care settings including inpatient care.
-Ability to function independently and as a team member.
-Knowledge of ICD and DSM IV coding or most current edition.
-Ability to analyze specific utilization problems and creatively plan and implement solutions.
-Able to demonstrate the ability to quickly develop an alliance with providers via telephone.
-On call coverage of Nurse Line as requested or required of position.
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