Utilization review nurse jobs in Hialeah, FloridaCreate job alerts

Job Description POSITION PURPOSE: Provide nursing care for selected patients under skilled nursing (RN) supervision. Assist in delivery of health care as member of team. POSITION REQUIREMENTS / QUALIFICATIONS: Education/Experience: Graduate from a standard High School or GED equivalence. Graduate from an approved Licensed Practical Nurse Program. One to two years experience in acute care or ambulatory care setting desired. Licensure / Certification: Licensed to practice as a LPN in the State of Florida. Maintain current CPR certification from the American Heart Association. Maintain current First Aid certification; First Aid certification must follow American Heart Association guidelines. Skills / Ability: Bilingual skills (English/Spanish, English/Creole) desired. Must have excellent communication skills. Ability to type 25 WPM. Basic computer knowledge desired. POSITION RESPONSIBILITIES (THIS IS A NON-EXEMPT POSITION) QUALITY OF WORK Consistently gives accurate attention to all details. Communicates effectively and expresses ideas clearly; actively listens and always follows appropriate channels of communication Consistently greets patients and treats patients respectfully. Follows standard Nursing Policies and Procedures for all care given. Administers all medications ordered by the provider using standardized safe guards to ensure safety and accuracy Follows M-DCPS guidelines and protocols for Medication Administration in the schools. Delivers health care teaching to patients at the level they can understand. Participates in Performance Improvement activities and compiles accurate observations for reports. Participates in the monitoring process that assures that all equipment and supplies are available and safe for patient care. Participates in tracking PAP’s, immunizations and any other preventive health measures. Demonstrates concern for patient flow. Always cross checks paperwork to ensure accuracy of medical records. Anticipates provider’s needs when preparing patients. Follows Policies and Procedures for infection control. Prepares areas for next day’s patient’s care to maintain patient flow; very thorough and accurate. Cleans area for next day patients care to reduce delays. Knowledgeable and comfortable with Intergy (EHR) System. Follows established policies for Health Information Management in the School Based Setting. Completes accurate and timely documentation in EHR within the same day of intervention. Provide students with parental consent forms to be completed by parent or guardian. Check students for official hall pass to the School Based Center. QUANTITY OF WORK Produces a consistent volume of acceptable work. Prioritizes tasks assigned and requests help as needed to maintain productivity. Completes assigned tasks in a timely manner. Finds appropriate tasks to do in down time. Assists team members with other tasks to improve patient satisfaction. Always able to carry out providers’ orders timely and accurately to expedite patient care. Willing to accept other duties not ordinarily assigned to expedite patient care; team player. Completes reviews and assessments of student records such as the cumulative health record and emergency health information. Completes collection of accurate data for reporting for the program funder The Children’s Trust. Contacts parents of students who are out of compliance with immunizations. Collects and tracks the number of parental consents for both medical and oral health services. Conducts mandated health screenings/follow-ups and completes accurate data collection for program funder The Children’s Trust. Collects Chronic Disease data, Students Requiring Medication & Procedures for reporting to the program funder The Children’s Trust. Conduct oral health risk assessments and screenings, administers fluoride varnish applications with parental consents. Assists with planning, coordinating and tracking the number of Child Specific Training provided to parents, school faculty, and students. Conducts, tracks, reports and documents all health education provided. Assists with the development, review and revision of the individualized student health care plan (IHCP), with parental consent. Tracks required data for reporting purposes to the funder The Children’s Trust. KNOWLEDGE OF JOB Possesses general knowledge of the CHI System, procedures, location of all departments, treatment areas and other patient services. Adheres to Departmental Policies and Procedures in performing duties and assignments. Generally knowledgeable regarding the required work to be done. Demonstrates the ability to work with a diverse population. Understands the importance of the computer environment and is willing to learn new skills. Discharges patients, taking off providers’ orders for follow-up care and treatment. Knows the limitations of job and reports appropriately to the supervisor. Follows established Policies and Procedures for administering medication. JUDGEMENT AND DECISION MAKING Seeks guidance and direction as necessary for the successful completion of job duties. Consistently combines ethical judgment with technical skill within the policies and legal guidelines of CHI. Follows written and verbal instructions as directed. Always attempts to understand co-workers needs and responds accordingly. Recognizes his/her role in the department and how it relates to the overall function of CHI. Actively participates as a team member and adds to the morale of the unit. Triages each patient in privacy under the guidance of the supervisor or the provider. Assesses and reports medical findings to the patient’s provider. Documents medical or any interaction with a patient. Completes B&E (billing and encounter) forms within the same day of intervention. Provides accurate and timely documentation in patient charts within the same day of intervention. PLANNING AND TIME UTILIZATION/INITIATIVE Consistently uses available time to departmental advantage and assists where needed. Adapts and is flexible in order to meet changing departmental needs and priorities. Consistently performs as a self-starter who needs no reminders of duties and/or tasks which need to be completed. Reports to the supervisor any suggestions for changes in Policies or Procedures that would improve efficiency. Initiates new ideas and shares with team members. Dependable when called upon to assist in departmental needs. Assists with monitoring patient’s rooms to maintain OSHA guidelines, i.e. PPEs in rooms, etc. RELATIONS/CARE Consistently maintains work area in a clean and orderly condition. Observes CHI’s Uniform Dress Code and wears identification badge at all times. Performs all daily functions in accordance with CHI Policies and Procedures. Recognizes and evaluates personal strengths and weaknesses; handles personal and professional frustration appropriately. Adheres to emergency procedures, fire drills, evacuation procedures and internal/external disaster plans. Conducts visual inspection of Fire Extinguisher in or near School Based Center (Health Suite). Assists in obtaining Fire Drill reports to meet Joint Commission requirements Relates and interacts well with others, regardless of sociological background. Handles all communications, including telephone information requests with courtesy, accuracy and respect for confidentiality; receives information and distributes messages as necessary. Respects the rights, privacy and property of others at all time. Establishes a good rapport and professional working relationship with all departmental personnel; maintains appropriate interdepartmental personnel; maintains appropriate interdepartmental communications. WORK HABITS Reports to work on time and ready to work with minimal absenteeism Never abuses or takes advantage of sick time or personal leave days. Provides proper notification and advance notice of absence or tardiness. Returns to work on time from lunch or breaks. Maintains current license and/or meet continuing education requirements. Staff due for renewal must complete the fingerprinting renewal process within (4) months prior to the expiration date of the original fingerprinting date. The renewal process is only complete once the picture ID is obtained. Reimbursement will be provided upon proof of receipts. Attends in-service training when scheduled. Adheres to Infection Control Policies and Procedures, including Universal Precautions. Utilizes Personal Protective Equipment appropriately such as, but not limited to, gloves, face shields or masks and eye protection to prevent the transmission of blood borne pathogens. Follows department and CHI’s safety policies. Reports safety hazards immediately when identified. Provides proper notification and advance notice for absence or tardiness. Adheres to Confidentiality Policies and Procedures / HIPAA Regulations. Performs other duties as assigned, including variable shifts if needed, travel from school to school is required as needed.

Job DescriptionAbout us: Solis Health Plans is a new kind of Medicare Advantage Company. We provide solutions that are more transparent, connected and effective for both our members and providers. Solis was born out of a desire to provide a more personal experience throughout all levels of the healthcare journey. Our team consists of expert individuals that take pride in delivering quality service. We believe in a culture that collaborates and supports one another, and where success is interlinked and each employee is valued. Please check out our company website at to learn more about us! Position is FULLY ONSITE Monday-Friday. BILINGUAL IN ENGLISH AND SPANISH IS REQUIRED Full benefits package offered on the first on the month following date of hire including: Medical, Dental, Vision, 401K plan with a 100% company match! Our company has doubled size, and we have experienced exponential growth in membership from 2,000 members to over 10,000 members! Join our winning Solis Team! Position Summary: The UM Care Coordinators are instrumental in helping patients receive great care with the attention and follow-up they need for optimal healthcare experiences. This requires a flexible attitude, quick thinking and a caring disposition. Key Responsibilities: • Scheduling UM Authorization and Determination tasks, • Refers all services requiring prior authorization to UM Nurse or BH UM Nurse as appropriate Manage determination placement, • Communicate with nurses and physicians, • Receives and responds to telephonic inquiries from providers regarding status of authorization requests and other questions or concerns, • Guides practitioners to appropriate referral resources, • Handle inbound calls and answer member and provider questions, • Connect with new members via phone and email as requested, • Communicate with members to determine and confirm their needs, • Arrange and coordinate special equipment or therapy for at-home care, • Maintain files and company information as required, • Provide timely data entry referrals for continuing care as necessary, • Perform benefit approvals on services, procedures, and tests that are listed on the UM Coordinator’s approval list. (These services do not require clinical judgment nor are reviewed for medical necessity. This list is reviewed as needed and at least annually for continued use by the UM Coordinator), • Process routine referral services that do not require a Prior Authorization, • Ensures timely printing and mailing of pre-certification, authorization and denial letters, • Appropriately documents interactions and activities into the UM electronic system, • Produces reports from UM electronic system for review and analysis by appropriate Leadership team member, • Assist the company care team with goal setting, • Ensures compliance with all federal, state, and local regulations., • Help with member data collection including medical records, HRA, etc., • Maintain patient confidentiality, • Post High School graduate courses or equivalent with significant experience in healthcare related customer service position; or equivalent combination of education and experience, • Insurance experience in the Medicare and managed care field is preferred, • Knowledge of CMS guidelines and InterQual is preferred, • Excellent computer knowledge is required, including proficient knowledge of Microsoft Office, • Strong decision-making and organizational skills, • Excellent listening, interpersonal, verbal and written communication skills with individuals at all levels of the organization, • Must be able to work with little or no supervision, • Willingness and ability to function independently and as a team member, • Working Knowledge of medical terminology, • Ability to handle multiple functions and prioritize appropriately, • Ability to meet strict deadlines, • Must be patient in dealing with an elderly population and sympathetic to hearing or vision deficiencies, • Ability to read, analyze, and interpret technical procedures or governmental regulations, • Ability to define problems, collect data, establish facts, and draw valid conclusions, • Strong decision-making, analytical skills, • Must be self-motivated, organized and have excellent prioritization skills, • Must be able to work well under stressful conditions Join Solis Health Plans as a Utilization Management Coordinator and become a catalyst for positive change in the lives of our members. At Solis, you will be part of a locally rooted organization deeply committed to understanding and serving our communities. If you are eager to embark on a purpose-driven career that promises growth and the chance to make a significant impact, we encourage you to explore the opportunities available at Solis Health Plans. Join us and be the difference!

Job DescriptionSalary: Open **IMMEDIATE OPENING Job Highlights The Case Manager will be responsible for coordinating and overseeing the care of patients, collaborating with healthcare providers, and ensuring the delivery of high-quality, personalized care. The role involves assessing patient needs, developing care plans, monitoring progress, and advocating for patients. Coordinates patient care in compliance to regulations and quality improvement of the Home Health Agency; order and authorization review, assignment of field staff, utilization management, the nursing process- development planning, implementation, and updates of the plan of care under the scope of the state RN licensure. The Case Manager prepares transfer and discharge summaries, maintain patient census, and assures interdisciplinary case coordination. Qualifications • MUST HAVE HOME HEALTH EXPERIENCE, • MUST HOLD A REGISTERED NURSE (RN) LICENSE, • Minimum of an Associates degree, BSN preferred., • Minimum of three (3) year of related experience in home healthcare, • Active Registered Nurse (RN) license in the State of Florida, • Strong organizational and time management skills, • Excellent communication and interpersonal skills, • Ability to work effectively in a team environment, • Experience in case management or healthcare coordination, • Knowledge of healthcare regulations and patient advocacy, • Empathy and compassion for patients and their families', • Knowledge of EMR and computer programs a plus Responsibilities • Develop individualized care plans based on assessment findings, • Collaborate with other healthcare professionals to coordinate patient care, • Monitor and evaluate the effectiveness of nursing programs and make recommendations for improvement, • Ensure compliance with all regulatory requirements, including HIPAA and medical record documentation, • Collaborate with other healthcare professionals to develop and implement patient care plans, • Develop and implement nursing policies and procedures to ensure high-quality patient care, • Document all patient interactions, interventions, and outcomes accurately and timely Benefits: • Pay: Open, • Location: In-Person/Remote, • Job Type: Full Time, • Hours of Operation: Monday thru Friday, • On Call, • Weekends PRN Special Requirements • Must have a car with required insurance coverage and a state driver's license or reliable transportation Functional Abilities • Able to communicate verbally and in writing to the extent required by the position, • Able to physically perform the duties required by the position

Job DescriptionAbout us: Solis Health Plans is a new kind of Medicare Advantage Company. We provide solutions that are more transparent, connected and effective for both our members and providers. Solis was born out of a desire to provide a more personal experience throughout all levels of the healthcare journey. Our team consists of expert individuals that take pride in delivering quality service. We believe in a culture that collaborates and supports one another, and where success is interlinked and each employee is valued. Please check out our company website at to learn more about us! Bilingual in English and Spanish is required Full benefits package offered on the first on the month following date of hire including: Medical, Dental, Vision, 401K plan with a 100% company match! Our company has doubled size and we have experienced exponential growth in membership from 2,000 members to over 10,000 members! Join our winning Solis Team! Position is fully onsite Monday-Friday. Location: 9250 NW 36th St, Miami, FL 33178. Position Summary: Under the supervision of the Health Services Director, the Utilization Management Nurse (LPN or RN) uses a multidisciplinary approach to organize, coordinate, monitor, evaluate, create and manage organization determinations and authorizations. These service requests will focus on selected complex medical and psychosocial needs of Solis Health Plans members. The UM Nurse is responsible for assuring the receipt of high quality, cost efficient medical outcomes for enrollees. This role works with Medical Directors, Authorization Coordinators and Service Coordinators to perform first level review to pre-certify elective services, procedures and tests utilizing established Care Coordination polices and protocols, Solis Health Plans benefit criteria, applicable regulatory review criteria and nationally accepted criteria for medical necessity determination. Main Key Responsibilities: • Conduct concurrent and retrospective utilization review for inpatient, observation or SNF services., • Conducts clinical reviews of proposed services against appropriate criteria/guidelines to determine medical necessity, benefit eligibility, and network contract status., • Work with Medical Directors, Program Leadership and Solis Health Plans Provider Relations Teams to identify and mitigate facility barriers associated with the ability to make timely decisions., • Identify, align and utilize health plan and community resources that impact high-risk/high cost care., • Act as liaison between assigned facilities, members/families, and Solis Health Plans. Clarify policies/procedures and member benefits as needed. Authorizes services, coordinates care, and ensures timeliness and coordination of healthcare services, in compliance with department and regulatory standards, seeking supplemental services when appropriate or when needed., • Assess enrollee needs and monitor progress toward goals at all times, communicating findings and status with members of the enrollee’s primary care team., • Ensure optimal delivery of safe quality health care to members, while maximizing resources and containing costs, and facilitate continual patient-centered and outcome-driven health performance improvement activities., • Review enrollees with the Medical Directors and Primary Care Teams and advocates for Administration Exception considerations as appropriate., • Graduate from an accredited school of nursing, or Bachelors (or advanced) degree in nursing., • Active and unrestricted licensure as a Registered Nurse in Florida., • A minimum of three to five years clinical experience as a Registered Nurse in a clinical setting required., • 2 years’ experience as a Utilization Management nurse in a managed care payer preferred., • One year experience as a case manager in a payer or facility setting highly preferred., • Discharge planning experience highly preferred. What Sets Us Apart: Join Solis Health Plans as a Utilization Management Nurse and become a catalyst for positive change in the lives of our members. At Solis, you will be part of a locally rooted organization deeply committed to understanding and serving our communities. If you are eager to embark on a purpose-driven career that promises growth and the chance to make a significant impact, we encourage you to explore the opportunities available at Solis Health Plans. Join us and be the difference!

Job Description Position Summary: The individual in this position has overall responsibility for hospital utilization performance improvement and operational management of the Case Management Department to promote effective utilization of hospital resources, ensure processes support appropriate reimbursement for services rendered, support efficient patient throughput, and ensure compliance with all state and federal regulations related to case management services. This position integrates national standards for case management scope of services including: • Utilization Management supporting medical necessity and denial prevention., • Transition Management promoting appropriate length of stay, readmission prevention and patient satisfaction., • Care Coordination by demonstrating throughput efficiency while assuring care is the right sequence and at appropriate level of care., • Compliance with state and federal regulatory requirements, TJC accreditation standards and Hospital policy., • Manage department operations to assure effective throughput and reimbursement for services provided,, • Lead the implementation and oversight of the hospital Utilization Management Plan using data to drive hospital utilization performance improvement,, • Ensure medical necessity review processes are completed accurately and in compliance with CMS regulations and Steward policy,, • Ensure timely and effective patient transition and planning to support efficient patient throughput,, • Implement and monitor processes to prevent payer disputes,, • develop and provide physician education and feedback on hospital utilization, Required qualifications include an active Registered Nurse license with at least two years acute hospital case management leadership experience preferred. MSN preferred. Accredited Case Manager (ACM) preferred. McKesson InterQual® experience preferred. Five years acute hospital case management experience preferred. Required skills include demonstrated organizational skills, excellent verbal and written communication skills, ability to lead and coordinate activities of a diverse group of people in a fast-paced environment, critical thinking and problem-solving skills and computer literacy. Business planning experience preferred. Training Requirement Must complete InterQual education course within 30 days of hire (and at least annually thereafter) and pass with a score of 85 or better. Must complete and demonstrate competency in using the Case Management documentation system within 30 days of hire. Attendance at hospital orientation is required. Must work with regional Performance Management and Innovation (PMI) Case Management leader to complete PE Director of Case Management orientation within 90 days of hire. Primary Information, Tools and Systems Used • Patient data - hospital admission, discharge, transfer system, • Healthcare staff documentation related to patient care, • Regulatory and payor requirements, • Allscripts Care Management System, • McKesson Care Enhance Review Manager (CERMe) InterQual system, • Crimson, • Clinical data interface and secure faxing, • Patient Medical Record including Cerner and HPF, • Hospital Specific Clinical Software, • Enterprise Reporting: Decision Support reports, PMI reports, • Care Discovery, • Ability to effectively communicate in writing and orally with all levels of the organization. Must clear background and drug test required.