RN Utilization Management Nurse Sr. (Medicaid-InPatient) JR130851
Location: Must be within 50 miles / 1 hour commute of Tampa or Miami, FL offices. This is primarily a remote position but may be required to go in for meetings/training.
MUST RESIDE IN THE STATE OF FLORIDA.
Monday-Friday 8 am - 5 pm EST or 4/10 hour shifts to include a weekend day.
The Nurse Medical Management Sr serves as Team Lead for nursing staff who collaborate with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources for the most complex or elevated medical issues. Ensures medically appropriate, high quality, cost effective care through assessing the medical necessity of inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting by utilizing the applicable medical policy and industry standards, accurately interpreting benefits and managed care products, and steering members to appropriate providers, programs or community resources. Works with medical directors in interpreting appropriateness of care and accurate claims payment. May also manage appeals for services denied. Primary duties may include, but are not limited to:
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