Job Duties include but are not limited to the following:

• Evaluate members in the Acute Hospital, LTAC, Acute Inpatient Rehab and/or Skilled Nursing Facility for benefit determination, medical necessity and appropriate level of care
• Participate in weekly case review
• Plan, implement, coordinate and monitor care coordination activities that focus on acute and non-acute services, outpatient services and or community resources for Medicare Advantage lines of business
• Monitor member’s discharge status, identify and coordinate any additional needs or services for successful discharge/transition in care
• Collaborate with Medical Directors, Managers, Peers and other departments (e.g. Case Management)
• Responsibilities are not all inclusive (e.g., project work may be requested in addition to other responsibilities)
• Moderate to heavy keying required.

Requirements:

• Current Florida RN license
• 2+ years of recent (within the past 3-5 years) clinical experience in a Hospital, LTAC, Rehab, SNF setting evaluating hospital benefit determination, medical necessity and appropriate level of care, esp. Utilization Management
• Experience in one or more of the following: Utilization Review, Discharge Planning or Case Management
• Experience with the Healthcare industry and Managed Care
• Proficient in MS Word, Excel and multiple computer applications
• Knowledge of NCQA/CMS Standards
• InterQual/MCG (Milliman) Care Guidelines
• Occasional travel within the State of Florida

Preferred skills:

• Bachelor’s degree in related field (i.e. Nursing, Healthcare, Business)
• Case Management Certification (CCM)
• Bilingual

Can be remote anywhere in Florida.