Licensed Utilization Review Ld (RN)
Elevance Health

Job Info

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Simply Healthcare Plans, Inc. is a proud member of Elevance Health's family of brands. We are a licensed health maintenance organization with health plans for people enrolled in Medicaid and/or Medicare programs in Florida.

Licensed Utilization Review Ld

Location: This is a remote position. The selected candidate must reside in the state of Florida.

This position requires level 2 background check.

Schedule: This position will work a 1st shift from 8:00 am- 5:00 pm (EST), Wednesday thru Sunday. Additional hours or days may be required based on operational needs (holiday rotation - 10% weekend differential).

The Licensed Utilization Review Ld is responsible for collaborating 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.

How you will make an impact

Primary duties may include, but are not limited to:

• Conducts pre-certification, 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 consistent with the members eligibility, benefits and contract.
• Develops working partnerships and collaborative relationships with physicians, healthcare service providers, and internal and external customers to help improve health outcomes for members.
• Accesses and consults 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.
• Serves as a Team Lead and responds to the most complex medical issues/ cases, assist in training, audits.
• Assist with staff assignments, coordination of staffing areas, monitor staff for production goals.
• May lead cross-functional teams, projects, initiatives, and process improvement activities.
• May serve as departmental liaison to other areas of the business unit or as a representative on enterprise initiatives.

Minimum Requirements:

• Requires a HS diploma or equivalent and a minimum of 2 years of clinical or utilization review experience and minimum of 3 years of managed care experience; or any combination of education and experience, which would provide an equivalent background.
• Current active unrestricted license or certification as a LPN, LVN, or RN practice as a health professional within the scope of licensure in applicable state(s) or territory of the United States required.

Preferred Skills, Capabilities, and Experiences:

• BSN in nursing highly preferred.
• Current active unrestricted license or certification as a RN practice as a health professional within the scope of licensure in applicable state of Florida.
• Minimum of 2 years of Long-Term Care clinical or Long-Term Care utilization review experience and minimum of 3 years of managed care experience strongly preferred.
• Previous Medical Review and/or Prior Authorization/Pre-Certification experience highly preferred.
• Certification in the American Association of Managed Care Nurses is preferred.
• Knowledge of the medical management processes and the ability to interpret and apply member contracts, member benefits, and managed care products is strongly preferred.
• Supervisor experience preferred.
• Proficient in Microsoft Office.

For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.

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