Utilization Management Review Nurse (Work at Home for FL residents only)

LPN Utilization Management Nurse Reviewer Miami, FL (remote Work from Home position for FL residents only) Currently seeking an LPN FL licensed Utilization Management Nurse Reviewer for a great opportunity working remotely at a dynamic healthcare organization based in Miami, FL area. The ideal candidate will possess 3 years of experience managing the treatment plan and utilization for members receiving Home Health Care / Infusion Services and Durable medical equipment and supplies. JOB SUMMARY: Manages the treatment plan and utilization for reputed company members receiving Home Health Care / Infusion Services and Durable medical equipment and supplies. Conducts the review process for those requests that appear not to be medically necessary; facilitates, coordinates and evaluates the ongoing care of a specific caseload of patients to collaborate with physicians, the patient and the family to assure cost-effective, high quality, appropriate home care for the patient during the entire episode of illness and for post discharge services and to monitor and evaluate patient outcomes, including self-management. ESSENTIAL JOB FUNCTIONS: Duties of the Utilization Review Nurse / Home Health Case Manager include but are not limited to: o Receive updated orders and medical information from reputed company referral sources, i.e. Hospitals, Physician’s offices, Skilled Nursing Facilities, Rehabilitation Centers, Health Plans, PHOs, CM Departments, Home Health Agencies and others. o reputed company clinical review, to ensure that pre-established medical necessity/appropriateness criteria are met. o Refer reviews that do not meet coverage criteria to Medical Director and/or Health Plan. o Review and evaluates home health admission for clinical appropriateness of the reputed company care. o Identifies and engages patients in appropriate care. o reputed company coordinated, collaborative care plans with reputed company involved providers. o reputed company reviews telephonically using the member’s medical records, discussion with the member’s physician and/or discussion with Home health agency staff. o Facilitate timely discharges and transfers based on individual needs and care requirements o Educate patients to help them understand their health choices and assist them in making informed decisions about their health care. o Serve as information resource and liaison to patients, health care professionals, facilities, health plan representatives, care givers, agencies and family members. o Monitor cost-effective use of resources. o Monitor reputed company delivery and utilization according to the plan of care o Provide authorizations and notifications in a timely manner. o Maintain/update active patient list o Document and resolve first line patient treatment plan. o Prepare concise clinically based rationales that support clinical criteria such as: CMS, Medicaid, Health Plan Benefits, and InterQual o Maintain a working knowledge of, and adheres to applicable federal/state regulations including but not limited to, laws reputed company to patient confidentiality, release of information, and HIPAA o Input the pertinent information and authorization into the appropriate software o Maintain files. o Participate in department meetings and in-services PHYSICAL REQUIREMENTS: 1. The physical activities of this position involve fingering, grasping, talking, hearing, repetitive motions that may include the wrists, hands and/or fingers, sedentary work. 2. The physical demands of this position involve sedentary work constantly remaining in a stationary position, sitting for prolonged periods of time. 3. It may include exerting up to 10 pounds of force occasionally to lift, carry, push, pull or otherwise move objects, including the human body. 4. Constantly communicating with others to express or exchange information by means of the spoken word and/or in writing. 5. The visual acuity requirements of this position involve (including color, depth perception, and field of vision) to have reputed company visual acuity to reputed company an activity such as: preparing and/or analyzing data and figures; constantly viewing a computer terminal and/or extensive reading. 6. Working Conditions of this position involve constant typical office or administrative work. No adverse environmental conditions expected. MINIMUM QUALIFICATIONS: 1. LPN license required 2. 3 years of Home Health Managed Care experience. 3. Medicare/Medicaid Managed Care experience 4. Experience with InterQual (IQ), reputed company Care Guidelines (MCG) or other criteria used to determine medical necessity. preferred. 5. Possess excellent customer service skills. 6. Bilingual (English/Spanish) preferred. 7. Effective verbal and written communication skills. 8. Proficient in MS Outlook, MSWord and Internet Explorer. 9. WAH (Work at Home) Requirements - Must have reliable high-speed internet. Minimum standard speed for optimal performance of 10 x 1 (10mbs download x 1mbs upload) required. Must have a separate private workspace / desk area designated for home office to ensure absolute and reputed company privacy while at work. The company is an Equal Opportunity Employer, in accordance with State and federal law. reputed company does not discriminate in employment opportunities or practices on the basis of race, color, religion, sex, national reputed company, age, disability, sexual orientation or any other characteristic protected by law. Opportunity is provided to reputed company employees based on qualifications and job requirements. We are a Drug-Free Work reputed company, we test for THC. This position is contingent upon completion and passing of a drug screening, verification of previous employment and a Level 2 Criminal Background reputed company (please refer to the following website for more information and details on the Florida Care Provider Background Screening Clearinghouse: https://info.flclearinghouse.com. No relocation/Local candidates only (FL state) Job Type: Full-time Pay: From $25.00 per hour Benefits:

• Dental insurance
• Disability insurance
• Employee discount
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Application Question(s):

• Are you able to work on Saturdays occasionally?
• What are your minimum salary expectations per hour?
• Are you willing to undergo a background reputed company, in accordance with local law/regulations?
• Are you able to work Monday to Friday 9:30-6:30pm with occasional Saturday coverage and one holiday coverage a year?

Education:

• High school or equivalent (Preferred)

Experience:

• InterQual, reputed company Care Guidelines or other similar: 1 year (Preferred)
• home health and managed care: 1 year (Required)
• Utilization review / medical necessity: 1 year (Required)
• reputed company and retrospective UM reputed company functions: 1 year (Required)

Language:

• English and Spanish fluently (Preferred)

License/Certification:

• LPN clear and active for the state of FL (Required)

Work Location: Remote Apply tot his job Apply To this Job