[New Job Opening] Utilization Review Nurse – Remote – Work from Home job Vacancy in Remote


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Utilization Review Nurse – Remote – Work from Home
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Description : You are a Nurse…an RN. You would love to work from home….Monday – Friday, 8 AM – 5 PM….and if needed occasionally be available for On-call during weekends…but still work from home. Correct?Then this job is for you!Ultimate Health Plans, Inc. (“UHP”) is a fast growing Medicare Advantage health plan with its headquarters located in Spring Hill, Florida. UHP plans provide all the benefits of Original Medicare Parts A and B, plus additional benefits not available with Original Medicare.Summary: The Utilization Nurse Reviewer engages by reviewing specific prior authorizations against accepted criteria, referring those cases that do not meet criteria, in whole or in part, to the Medical Director for a determination, by performing the following duties.Essential Duties and Responsibilities: · Participates in the review process, including inpatient hospital, skilled nursing facility, inpatient rehab, and long term acute care as well as preservice and retrospective reviews (Part B) according to specific chosen criteria such as, but not limited to CMS’ national and local coverage determinations (NDCs/LCDs) and Health Plan coverage guidelines, for approval or referral to a Medical Director.· Reviews the Prior Authorization Listing (PAL) and assists with periodic revisions with the UM Nurse Review Manager.· Ensures cases are referred to the Medical Director when the treatment request does not meet medical necessity guidelines in whole or in part, or when a peer-to-peer conversation is necessary to establish appropriateness.· Ensures referrals to the Medical Director(s) are made in a timely manner, allowing the physician time to make appropriate contact with the requesting provider in accordance with departmental policy and within state and federal guidelines or NCQA mandated turnaround times.· Communicates with members of the treatment team when necessary.· Assists with the reviews of medical records, using clinical expertise and compares information to established guidelines, Health Plan coverage guidelines, NCDs/LCDs, Interqual, and the member’s benefit plan.· Participates in orientation and departmental training programs.· Acts as a training mentor, if selected by the UM Manager.· Relies on clinical support/review from Medical Director. Discusses cases and accesses the Medical Director electronically or telephonically whenever necessary.· Completes Inter-Rater Reliability (IRR) at least annually to staff.· Provides consistency in UM decisions.· Adheres to all confidentiality, PHI, HIPAA and privacy requirements.· Identifies and refers high-risk/high-cost patients for possible case management intervention and identifies patients with chronic disease processes for possible disease management intervention.· Assists in coordination and the delivery of cost-effective, quality-based health care services for health plan members.· Coordinates with providers of medical services and equipment to facilitate effective communication, referrals, and alternative treatment plan development.· Outreaches for relevant information if not present and documents same in Contacts section in the UM system.· Evaluates each case for quality of care, documents quality issues and appropriately refers cases with questionable quality of care in accordance with established policy.· Supports the organization’s Quality Management Program; participates in ongoing clinical quality improvement activities as it relates to internal programs and processes, studies, projects or medical record review as directed by the UM Manager.· Addresses the needs of internal and external customers; including co-workers, internal departments, Members, providers and vendors.· Ensures compliance with all state and federal regulations and guidelines in day-to-day activities.· Attends workshops and seminar to improve knowledge.· Participates in various task force and committee projects, as requested.· Other duties as assigned by UM Manager.Supervisory Responsibilities: NoneCertificates, Licenses, Registrations: RN with current unrestricted Florida LicenseComplex Case Management certification (CCM) a plusOther Skills and Abilities: No travel anticipated.Other Qualifications: At least 2 years’ experience in Managed Care and Medicare preferred with 2 years work experience in a direct patient care setting, preferred.Department: Medical Care ManagementReports To: Director of Utilization ManagementFLSA Status: ExemptJob Type: Full-timeJob Type: Full-timePay: $65,000.00 – $70,000.00 per yearBenefits:401(k)401(k) matchingDental insuranceFlexible scheduleHealth insuranceLife insurancePaid time offVision insurancePhysical Setting:OfficeSchedule:Monday to FridayOn callEducation:Bachelor’s (Required)Experience:Clinical Documentation & Utilization Review Nurses: 1 year (Preferred)License/Certification:RN (Required)Work Location: Remote
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