Nurse Utilization Management l – In-Patient / 4 – 10’s / Thurs - Sun (JR7663)
Preferred Location: Tampa, Florida area. This is a work@home role. Qualified applicants must reside within a 50 mile commute to our local office. Will consider candidates in the Miami, Florida area.
NOTE: While the position is remote, occasional meetings and/or training will be required in the office in the future.
Work Hours : This position requires 4 days/week, 10 hr days. Thursday, Friday, Saturday, Sunday. 6am – 5pm. Rotating Holidays required.
The Nurse Medical Management l for Florida Medicaid is responsible to collaborate with healthcare providers and members to promote quality member outcomes, optimize member benefits, and promote effective use of resources. Accurately interprets benefits and managed care products, and steers members to appropriate providers, programs, or community resources. This role includes some utilization management and in-patient case management responsibilities. Primary duties may include, but are not limited to:
Conducts pre-certification, continued stay review, care coordination, or discharge planning for appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.
Ensures member access to medically necessary, high-quality healthcare in a cost-effective setting according to contract.
Consult with clinical reviewers and/or medical directors daily to ensure medically appropriate, high-quality, cost-effective care throughout the medical management process.
Collaborates with providers to assess members' needs for early identification of and proactive planning for discharge planning.
Facilitates member care transition through the healthcare continuum and refers treatment plans/plan of care to clinical reviewers as required and does not issue non-certifications.
Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards.
Works with medical directors in interpreting appropriateness of care and accurate claims payment.
May also manage appeals for services denied.
Current, unrestricted RN license from the state of Florida.
3+ years of acute care clinical experience; or any combination of education and experience, which would provide an equivalent background.
1 year experience using Microsoft Word, Excel, and Outlook.
Knowledge of the Utilization Management and/or Utilization Review process (within managed care or provider setting) experience is strongly preferred.
Prior Medicaid and/or managed care experience is preferred.
Please be advised that Elevance Health only accepts resumes from agencies that have a signed agreement with Elevance Health. Accordingly, Elevance Health is not obligated to pay referral fees to any agency that is not a party to an agreement with Elevance Health. Thus, any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.
Be part of an Extraordinary Team
Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. Previously known as Anthem, Inc., we have evolved into a company focused on whole health and updated our name to better reflect the direction the company is heading.
We are looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. You will thrive in a complex and collaborative environment where you take action and ownership to solve problems and lead change. Do you want to be part of a larger purpose and an evolving, high-performance culture that empowers you to make an impact?
We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.
The health of our associates and communities is a top priority for Elevance Health. We require all new candidates to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide – and Elevance Health approves – a valid religious or medical explanation as to why you are not able to get vaccinated that Elevance Health is able to reasonably accommodate. Elevance Health will also follow all relevant federal, state and local laws.
Elevance Health has been named as a Fortune Great Place To Work in 2021, is ranked as one of the 2021 World’s Most Admired Companies among health insurers by Fortune magazine, and a Top 20 Fortune 500 Companies on Diversity and Inclusion. To learn more about our company and apply, please visit us at careers.ElevanceHealthinc.com. Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact firstname.lastname@example.org for assistance.