Utilization Review Nurse (Positive Healthcare)
AIDS Healthcare Foundation - Fort Lauderdale, FL

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Positive Healthcare Partners (HMO SNP)

Positive Healthcare Partners is Medicare Advantage Prescription Drug health plan specifically for Medicare beneficiaries who are living with HIV and reside in Broward and Miami-Dade Counties.

Positive Healthcare Partners is the first HIV-specific special needs health plan approved by the Centers for Medicare & Medicaid Services (CMS). This plan covers routine doctor and specialist office visits, emergency and urgent care, hospitalization, and more. It also includes a prescription drug benefit for no monthly premium.

Positive Healthcare(R) Florida

A Medicaid Reform managed care plan designed specifically for HIV-positive individuals.

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Utilization Review is the process in which medical review determinations are made based on clinical guidelines and structured processes. This position reviews the utilization of the organization/plan's resources against established criteria, monitors and evaluates the medical necessity, appropriateness and efficient use of health care services. The position also provides reports and recommendations for improved utilization of resources while maintaining quality of care to the UM/CM Mgr.., Director of Managed Care and the Chief of Managed Care.

Essential Duties and Responsibilities:
Pre-admission, concurrent and retrospective acute care, sub-acute, hospice, transitional care & long term care to determine whether or not an admission is, or remains to be, reasonable and medically necessary, using established criteria, e.g., Milliman and Robertson, InterQual, Medicare or Medicaid, or AHF Best Practice criteria

Performs case reviews in a timely manner and maintains all required documentation of clinical reviews in the appropriate database.

Issues authorizations to Providers and assists Plan Medical Director in the issuance of other required communications (such as denials) per established guidelines, and in compliance with all applicable Medicare or Medicaid guidelines.

Collaborates with the Primary Care Provider and/or attending physician, internal and external case managers, patient and/or family and other healthcare providers to provide continuity and quality of care in the most cost effective manner

Assists in the discharge planning process with both internal and external case managers/discharge planners and/or patient and family.

Concurrent Review and collaboration with internal case managers of all acute care, skilled nursing, acute rehabilitation, long term care, hospice and home with home care services admissions of Plan members.

Assesses each acute care hospital admission to determine the appropriate level of care, i.e., critical care, telemetry, step down, medical-surgical, administrative, etc.

Admission Reviews are performed within 72 hours of admission (for weekend admissions) and within 48 hrs. of all other admission, or as dictated by applicable policy and procedure.

Monitors and maintains Hospitalization Reports at the direction of UM/CM Mgr.

May attend clinical meetings with hospital based providers and staff regarding the care of plan members.

Coordinates closely with the Plan's Medical Director, referring cases that do not appear to meet established criteria.

Compiles and analyzes data for utilization review management activities.

Maintains logs and statistics as directed by UM/CM Mgr.

Provides outpatient or pharmacy services utilization review, based on UM/CM Dept. needs.

Prepares or assists in preparing weekly, monthly, quarterly and yearly and ad hoc utilization review reports as directed by UM/CM Mgr.

Assists in preparing an annual Utilization Management Program evaluation.

Other duties as assigned

Supervisory Responsibilities:
This position has no supervisory responsibilities .

Current Florida RN license

3 or more years of recent medical/surgical or critical care nursing experience

3 or more years of recent Utilization Review/Case Management Experience

Strong telephonic communication skills, ability to conduct high level clinical discussions with physicians and nurses

Ability to successfully work with various levels of professional staff; must work well independently and as part of a team

Language Skills:
Fluent in English

Mathematical Skills:
College level Algebra and Statistics

Physical Demands:
No heavy lifting. Must be able to work at a desk or computer workstation.

Work Environment:
Office Setting


AIDS Healthcare Foundation - 23 months ago - save job - copy to clipboard
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