Job Description: Job Duties include but are not limited to the following:
Evaluate members in the Acute Hospital, LTAC, Acute Inpatient Rehab and/or Skilled Nursing Facility for benefit determination, medical necessity and appropriate level of care
Participate in weekly case review
Plan, implement, coordinate and monitor care coordination activities that focus on acute and non-acute services, outpatient services and or community resources for
Monitor member s discharge status, identify and coordinate any additional needs or services for successful discharge/transition in care
Collaborate with Medical Directors, Managers, Peers and other departments (e.g. Case Management)
Responsibilities are not all inclusive (e.g., project work may be requested in addition to other responsibilities)
Moderate to heavy keying required.
Current Florida RN license
2+ years of recent (within the past 3-5 years) clinical experience in a Hospital, LTAC, Rehab, SNF setting evaluating hospital benefit determination, medical necessity and appropriate level of care, esp. Utilization Management
Experience in one or more of the following: Utilization Review, Discharge Planning or Case Management
Experience with the Healthcare industry and Managed Care
Proficient in MS Word, Excel and multiple computer applications
Knowledge of NCQA/CMS Standards
InterQual/MCG (Milliman) Care Guidelines
Occasional travel within the State of Florida
Business Specific Criteria (preferred skills):
Bachelor s degree in related field (i.e. Nursing, Healthcare, Business)
Case Management Certification (CCM)
Comments for Suppliers: ***Full time 40 hours/week - may include weekends.
***Concurrent Review for Medicate Utilization Management.