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1030 UM Nurse Reviewer

Tampa, Florida
Utilization Management Nurse Reviewer
Tampa, FL
Contract or Full Time

Minimum Qualifications:
  • Current Active and Unrestricted Nursing License required ( Associate Degree, Nursing Diploma  or Bachelor’s degree in Nursing)
  • 3 years combined clinical and utilization management experience in a managed health care plan preferred
Primary Responsibilities:
  • Performs utilization management reviews in accordance with federal and state regulations
  • Maintains compliance with regulatory changes affecting utilization management
  • Perform UM reviews for inpatient services according to the NCQA, URAC, CMA & DOH standards and client requirements and/or policies
  • Reviews UM requests for services against established clinical review criteria, referring cases not meeting criteria to a physician reviewer
  • Adheres to Department of Labor, state and UM time frame requirements per contract
  • Coordinates physician reviewer referral as needed and follows up timely to obtain and deliver those results
  • Tracks status of all utilization management reviews in progress
  • Releases UM determinations to claim stakeholders following client-established protocols
  • Works closely with management team in the ongoing development and implementation of utilization management programs
  • Certifies reviews that meet clinical review criteria/guidelines
  • Adheres to quality standards and UM guidelines
  • Maintains all required utilization management review documentation in the UM software in a timely manner
  • Refer cases to case management as indicated/appropriate
  • Responds to inbound telephone calls pertaining to UM reviews in a timely manner, following client-established proto
  • Maintains confidentiality of all information, policies, and procedures as required by the Health Insurance Portability and Accountability Act (HIPAA) protocols
  • Maintains acceptable levels of performance including but not limited to attendance, adherence to protocols, customer courtesy, and all other productivity and efficiency targets and objectives
  • Learns new methods and services as the job requires
  • Advises supervisor of any potential problems as they become evident
  • Manages assigned workload within established performance & productivity standards
  • Attends meetings to achieve departmental goals and objectives
  • Able to work rotational shifts with adherence to schedule a must, including evenings, weekends, holidays and overtime as necessary
Technical Recruiter
ReqRoute, Inc
Phone: 415-691-4708
Email: sudhanshu@reqroute.com
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