RN Medical Management Coordinator Utilization & Case Review

DOCTORS HEALTHCARE PLANS, INC.; Miami (FL); On-site; USD 60,000 - 90,000; Full time

Job summary

Uloop Inc. is seeking a Utilization Management professional to review medical necessity for home care and elective services, ensuring alignment with plan criteria and regulations.

The role involves documenting in the UM system, coordinating with pre-authorization teams, and advocating for appropriate resource use. The ideal candidate will have 2+ years in pre-authorization, utilization review, case management, and discharge planning, with strong communication and analytical skills, and the

Qualifications

• Minimum 2 years of experience with pre-authorization, utilization review/management, case management, care coordination, and/or discharge planning.

Responsibilities

• Manages cases requiring medical necessity review such as home care, elective inpatient and outpatient service requests.
• Reviews cases referred by the prior-authorization non-clinical medical management coordinator and pre-certification technician staff according to member benefits, provider availability, and pre-determined medical necessity criteria.
• Presents cases to ensure quality care while advocating for appropriate utilization of health system resources consistent with policy, criteria guidelines, and goals.
• Documents necessary information in Utilization Management system.
• Monitors and complies with state, federal and regulatory requirements.
• Responds to complex/in escalated inquiries using clinical expertise and knowledge of Utilization Management, claims and regulatory requirements.
• Identifies members who could benefit from care management and refers to the appropriate care manager.
• Identifies process issues and recommends/implements solutions.
• Suggests workflow and systems improvements to monitor and improve departmental performance indicators.
• Recognizes opportunities for new approaches to address needs of targeted members and improve outcomes.
• Maintains caseload volume and productivity standards.
• Collaborates with internal stakeholders and builds external relationships with providers, facilities, and vendors.
• Uses Utilization Management system proficiently.

Skills

Medical necessity review

Utilization management

Case management

Communication skills

Analytical/problem solving

Tools

MS Outlook

MS Word

MS Excel

Job description

Uloop Inc. is seeking a Utilization Management professional to review medical necessity for home care and elective services, ensuring alignment with plan criteria and regulations.

The role involves documenting in the UM system, coordinating with pre-authorization teams, and advocating for appropriate resource use. The ideal candidate will have 2+ years in pre-authorization, utilization review, case management, and discharge planning, with strong communication and analytical skills, and the