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Utilization Management Professional
Ref No.: 18-09882
Location: Orlando, Florida
Start Date / End Date: 09/05/2018 to 12/28/2018
Job Title: Utilization Management Professional (648529)
Location: Miami FL 33126
Duration: 4 Months

  • Under general supervision, and in collaboration with Medical Directors and other members of the clinical team, gathers and synthesizes clinical information in order to authorize services.
  • Reviews health care services to determine consistency with contract requirements, coverage policies and evidence-based medical necessity criteria;
  • Collects and analyzes utilization information; assists with program processes for transitions across levels of care including discharge planning and ambulatory follow up activity.
  • Serves as an expert resource on coverage policies, covered benefits, and medical necessity criteria.

  • Develops and manages new enrollee transitions and those involving a change in provider relationships.
  • Develops and implements transition plans, as indicated, to ensure continuity of care.
  • Negotiates and documents single case agreements according to the company's procedures.-
  • Reviews planned, in process, or completed health care services to ensure medical necessity and effectiveness according to evidence-based criteria.
  • Proposes alternatives when the requested services do not meet medical necessity criteria or are outside the contracted network.
  • As assigned and based on credentials, monitors and reviews specialized requests and treatment records such as Treatment Record Forms.-
  • In conjunction with providers and facilities, identifies, develops and monitors discharge plans. Collaborates with the Care Coordination Team to implement support for transitions in care.
  • Facilitates timely sharing of enrollees? clinical information (such as previous treatment, medications, and planned care) in order to promote continuity of care.-
  • Provides information to enrollees, providers, and internal staff regarding covered and non-covered benefits, community resources, agency programs, and company policies and procedures and criteria.-
  • Interacts with Medical Directors and Physician Advisors to provide case information and discuss clinical and authorization questions and concerns regarding specific cases.
  • Assures that case documentation for each decision is complete, including related correspondence.- Participates in Care Coordination Team and utilization management activities, including collaboration with other staff on enrollee cases, and performing data collection, tracking, and analysis.-
  • Maintains an active work load in accordance with performance standards.-
  • Works with community agencies as appropriate.- Participates in network development including identification and recruitment of quality providers as needed.-
  • Advocates for the enrollee to ensure health care needs are met. Interacts with providers in a professional, respectful manner. –
  • Provides coverage of Nurse Line and/or Crisis Line as requested or required for position.

  • LPN or RN required
  • Must have medical background
  • Will review medical procedures that need prior authorization
  • Client Complete Care prior authorization department is looking for an RN or LPN. This position is to review OP and IP elective Medical procedures for MNC.
  • RN or LPN. If not an RN, must hold Masters or Doctoral Degree.
  • If LPN, must work under the direct clinical supervision of a Registered Nurse (RN) Case Manager, Registered Nurse Utilization Management Professional (UMP), or Registered Nurse Clinical Manager.-
  • Ability to use computer systems.-Good organization, time management and verbal and written communication skills.-
  • Knowledge of utilization management procedures, Medicaid benefits, community resources and providers.-Knowledge and experience in diverse patient care settings including inpatient care.-Ability to function independently and as a team member.-
  • Knowledge of ICD and DSM IV coding or most current edition. –
  • Ability to analyze specific utilization problems and creatively plan and implement solutions. –
  • Able to demonstrate the ability to quickly develop an alliance with providers via telephone.-
  • On call coverage of Nurse Line as requested or required of position.
  • 3 years experience post degree in a clinical, psychiatric and/or substance abuse health care setting.
  • Also requires minimum of 3 years of experience conducting utilization management according to medical necessity criteria.
  • ClinicalRN - Registered Nurse, State and/or Compact State Licensure - Care Mgmt LPN
  • Licensed Practical Nurse - Care Mgmt Associates: Nursing (Required)