Why work with us? We are a woman-owned company that values your ideas, encourages your growth, and always has your back. When you work with us, not only do you get health and dental benefits on the first day of employment, but you also have training opportunities, flexible/remote work options, growth opportunities, 401K and competitive pay. Apply today! We are an EOE, all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran. https://www.optechus.com/eeo_self_identification/
Description:
This position serves as our client’s clinical expert in working with providers, facilities and subscribers in overseeing the wellbeing of subscribers while ensuring the proper administration of benefits, cost effectiveness, and the coordination of the delivery of quality care.
Essential functions:
• Conduct on-site review of subscriber’s medical information in order to ensure appropriate benefit administration.
• Consult with providers, facilities’ staff, subscribers and their families to ensure cost efficiencies in the delivery of care.
• Coordinate with internal and external sources in the on-going management of subscriber’s care.
• Gather and review subscriber’s medical information in order to schedule, based on criticality, on-site reviews. Apply clinical expertise in the completion of subscriber’s medical documentation, which become legal documents and part of subscriber’s file.
• Conduct weekly reviews with internal and external sources on the care and services provided by our client to subscribers. Compile weekly, monthly and quarterly reports used to determine cost savings, identify process improvement opportunities and document activities.
• Conduct training of new staff members and providers as needed.
Job Requirements:
• 1-year of utilization management experience
• ICD-9 Coding
• Excellent planning, organizational skills
• Excellent verbal and written communication skills
• Self-starter
• Ability to work independently
• Conflict resolution
• Detail oriented
• Ability to handle multiple tasks
• Decision making skills
• Flexibility
• Basic PC knowledge
• Managed care experience
• Understanding of Regulatory Agencies
Experience:
3+ years related work experience or equivalent combination of transferable experience and education
Combined experience in utilization management, case management, home health and clinical
Education:
Nursing – Related Bachelor’s degree required
Qualifications/Certificates:
Florida license – NursingRN – Registered Nurse – State Licensure And/Or Compact State Licensure
Florida license – Non-ClinicalAZDL – Driver License – Valid And In State
Preferred:
• Ability to work with multiple screens and systems
• Managed care experience, Including InterQual, NCD and LCD medical review criteria
• Understanding of Regulatory Agencies
• Medicare Advantage Experience
• Prior FLBL experience
Must:
• Previous CMS experience and review of all organization determinations, including pharmacy reviews.
• Top candidates are those that have Jiva, Seibel, and Diamond experience.
• Remote – Florida
• Must have a FL RN License – Unrestricted or Nursing Compact license
118535
