Utilization Review Nurse Coordinator Job at AvMed Health Plans
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Are you passionate about health, happiness and helping others? So are we. We’re committed to helping our health plan Members live a happy and healthy lifestyle, and we believe that it starts here first, with our Associates.
At AvMed, we provide the tools and opportunities to enhance, expand, and support each Associate’s personal and professional growth. From tuition reimbursement to exercise classes in the office, embrace a better career with AvMed and join our team!
Position: Utilization Review Nurse Coordinator
Scope of position: The UR Nurse Coordinator provides Member medical utilization management by utilizing nursing clinical assessment skills, approved medical necessity clinical criteria and benefit criteria to review authorization requests for appropriateness of medical treatment in the appropriate medical setting during the appropriate timeframe.
Essential Job Functions:
- Maintains an enhanced level of regulatory knowledge requirements for the authorization process; employs the ability to identify, prevent and escalate potential compliance issues. Participates in regulatory compliance audits.
- Conducts reviews for all requests based on medical appropriateness established by nationally accredited guidelines and internal procedures; Initiates second level reviews when submitted documentation fails to satisfy established guidelines and procedures.
- Offers the Provider/Member options and alternatives to requested services within clinical guidelines, benefits and established criteria to ensure that the Member receives the appropriate treatment, in the appropriate setting for the appropriate length of stay.
- Provides oversight of non-clinical team associates.
- Identifies potential problem areas of excessive utilization, and/or inefficient care delivery.
- Assists Members with transition of care/continuation of care benefit coverage with new enrollment or when Provider terminates from AvMed network.
- Functions as a liaison to promote an effective working relationship between AvMed’s providers, hospitals, contracted health care agencies and the member/caregiver.
- Ability and willingness to serve as a Subject Matter Expert (SME) in at least one specialty area within the Clinical Coordination Department.
- Exhibits superior written and verbal communication skill set to allow collaboration with department, AvMed, Providers, Members and compliance requirements.
- Performs additional duties and responsibilities as assigned by management.
We Offer:
- Competitive Salaries
- Comprehensive Benefits: Medical Plans, Health Savings Account, Dental, Vision, and more…
- Paid Time Off, Company Paid Holidays, Paid Time Off Cash-In
- 401(k)plan with matching contributions, Tuition Assistance, Associate Discounts
You have:
- Associates required
- Bachelor’s preferred
- Registered Nurse with an active and unrestricted FL license
- 3-5 years of clinical, managed care or utilization review experience required
- LPN with an active and unrestricted FL license with 5-10 years of health plan experience considered
- Three years of clinical nursing experience; hospital clinical experience preferred
- Certified Case Manager (CCM) or American Case Management Certification (ACM) preferred
You May Also Have:
- Experience with utilization review or management, discharge planning and/or clinical review.
- Working knowledge of ICD, CPT and HCPCS codes.
- Self-direction, critical thinking, independent functioning, excellent clinical and managed care skills, and teamwork oriented.
- Must be able to collaborate effectively with all members of the team, departments and AvMed providers.
- Strong presentation, documentation, and communication skills.
- Strong ability to multitask and manage multiple cases and initiatives simultaneously.
- Strong computer skillset.
- Bilingual in English and Spanish is a plus but not required.
Environment:
At AvMed, you will find a family. Our Associates love all the opportunities for advancement, the flexible work environment and team activities. We also encourage our Associates to embrace a life rich in what matters most — health and happiness. We call it being WELLfluent. Join AvMed. Join the WELLfluent!
Location: Miami or Gainesville, Florida
This position is Hybrid 2 days in office and 3 days remote
AvMed is a tobacco/drug free workplace, EOE
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