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Nurse Auditor in Tampa, FL at Accounting Now

Date Posted: 3/12/2020

Job Snapshot

  • Employee Type:
  • Location:
    Tampa, FL
  • Job Type:
  • Experience:
    Not Specified
  • Date Posted:
  • Job ID:

Job Description

The UM nurse assesses the medical necessity and quality of healthcare services by conducting the following types of requests: pre service, concurrent, and retrospective utilization management reviews.
Roles and Responsibilities
* Assesses the medical necessity, quality of care, level of care and appropriateness of health care services for plan members.
* Conducts outreach to requesting providers which can include specialty physicians, ancillary providers and institutions to gather the appropriate/necessary clinical data.
* Applies clinical review criteria, guidelines, and screens in determining the medical necessity of health care services against the clinical data provided.
* Certifies cases that meet clinical review criteria, guidelines and/or screens.
* Consults with physician when reviews do not meet clinical review criteria, guidelines, and screens.
* Refers cases to other professionals internally, including case management and medical consultation when indicated.
* Ensures the integrity and high quality of utilization management services.
* Adheres to accreditation, contractual and regulatory timeframes in performing all utilization management review processes.
* Strictly follows company policies related to the handling, release and disposal of confidential information.
* Ensures that the Operations Manager or designee is made aware of any potential risk management issues in a timely manner.
* Consistently meets medical management standards for attendance and punctuality.
* At all times treats others with dignity and respect.
* May require occasional overnight travel, particularly for training.
Job Qualifications and Requirements Education and Licensure:
* Education leading to the completion of an approved RN or LPN program
* Current, active and unrestricted US RN license. Florida RN license preferred but will consider other states.
* At least 1 year experience in utilization management with a health plan or hospital based UM dept. with use of Interqual or MCG.
* Prefer at least 3-4 years of clinical experience
* Current CCM credential is a plus