University of Florida UFL - Gainesville, FL

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Requisition Title

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Advertised Salary:
Starting salary is $15.00 to $20.00 per hour; commensurate within this range based on qualifications and experience.

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Work Location
Main Campus (Gainesville)

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Job Description:
This position works with the QI/UM Asst. Director to support the providers and members of the University of Florida, Department of Pediatrics, Integrated Care System ( ICS ), hereinafter referred to as “Ped-I-Care.” The purpose of Ped-I-Care is to provide comprehensive and cost-effective health care coverage to children with special health care needs in a twenty- three county area who qualify for coverage under Title XXI and Title XIX (Medicaid) of the Social Security Act. Ped-I-Care is a contracted entity of the Children’s Medical Services ( CMS ) network that serves as a managed care health plan for these children. Children enrolled in the Ped-I-Care are provided with a medical home that links primary, community-based services with a comprehensive array of specialty and tertiary care services. A multi-disciplinary and family centered approach to the provision of services is important and required to meet the needs of the member and his/her family. Contractual relationships have been established between Ped-I-Care, Department of Health ( DOH ), health care providers, the Third Party Administrator ( TPA ), and the CMS area offices to achieve a comprehensive and coordinated system of managed care that meets family needs while providing access to health care services in a cost-effective manner.

Work in conjunction with the QI/UM Asst. Director, other Quality Improvement LPNs, and Quality Improvement Assistants in planning, organizing, and scheduling site visits based on Ped-I-Care’s state contractual obligations and member numbers and claims at different providers and facilities within the Ped-I-Care provider network. Researching and reviewing member data in order to choose a wide selection of member charts for review. Verifying and making lists of all necessary information; keeping the appropriate people informed of changes/updates as they occur and are identified. Performing site visits for the purpose of reviewing charts, interviewing staff, and observing the facilities for safety and other quality issues to ensure adherence to State and Federal laws, governing agencies’ guidelines, and contractual obligations. These visits will be to PCPs, Specialists, Ancillary Providers, and Hospitals in the Ped-I-Care provider network.

Complete response letters to the providers detailing the findings of the completed site review. Responsible for collecting, organizing, following-up, and reporting data on all quality issues, site reviews, and chart reviews. Provides the QI/UM Asst. Director with all information collected during and following the review. Assists in reporting data, at least quarterly, to the Executive Director, Advisory Group, CMS , our Third Party Administrator, and the Quality and Utilization Management Committee. Ensures that the finalized site review information has been properly stored for Ped-I-Care’s records and sends approved feedback information to providers.

Maintain a professional working relationship and environment by demonstrating a cohesive and team building demeanor with all members of Ped-I-Care staff. Must effectively communicate with providers, members, parents/guardians, Ped-I-Care Medical Directors, CMS Nurse Care Coordinators (NCCs), the Ped-I-Care Third Party Administrator ( TPA ), and anyone involved in member care in order to ensure that members receive high quality care. Responsible for following up on concerns/complaints and documenting them in the log as directed. Accountable for keeping the appropriate parties notified of any issues, changes, or concerns relevant to site visits and quality issues. Notifies the QI/UM Asst. Director of any issues or concerns identified during the site review process or otherwise.

Ensure accurate and timely documentation of all quality improvement activities. Prepares for site visits. Participates in quality meetings and reviews. Assists with preparations for audits, both internal and external.

Review claims data and admission notes. Reviews member information, referrals, authorizations, medical reviews, appeals, and grievances as needed. Provides coverage for medical reviews and appeals as needed. Ensures adherence to State and Federal laws, governing agencies’ guidelines, and contractual obligations. Assesses for lapses in quality, care, and areas where improvements can be made. Participates in correcting problems and helps to follow up on issues of concern. Discusses with the QI/UM Asst. Director all issues, plans, and follow-up. Assists in submitting data at least quarterly to the Executive Director, Advisory Group, CMS , and the Quality and Utilization Management Committee.

Other duties as may be required.

Minimum Requirements:
Licensed as a practical nurse in accordance with Chapter 464, Florida Statutes*, or eligible to practice nursing in accordance with Section 210, Florida Administrative Code*.

Preferred Qualifications:
Healthcare experience or background required.

Computer skills required.

Attention to detail and experience preparing and proofreading correspondence and/or reports preferred.

Experience in physician and/or hospital patient care (preferably pediatrics), working knowledge of quality improvement practices and models, billing, claims processing and reimbursement, contract management, and/or working with a managed health care plan preferred.

Health Assessment Required:

Special instructions to applicants:
This is a repost of requisition number 0902237. Previous applicants are under consideration and need not apply.

Normal Work Schedule Monday – Monday through Friday, 8:00 AM – 5:00 PM, with occasional deviations to accommodate site visits; occasional overtime may be required.

Travel to practice sites will be required on most days of the week and the schedule will be adjusted to accommodate a 40 hour work week whenever possible.

This position is time limited.

If you are a Florida resident claiming veteran’s preference, please upload a copy of you DD-214 for consideration.

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