Medical Management Coordinator, RN
DOCTORS HEALTHCARE PLANS, INC.
- Coral Gables, FL
- Permanent
- Full-time
- Manages appropriate cases that require medical necessity review such as home care, elective inpatient and outpatient service requests.
- Reviews cases referred by the prior-authorization non-clinical medical management coordinator and pre-certification technician staff according to member benefits, provider availability, and pre-determined medical necessity criteria.
- Clearly and succinctly presents cases to ensure quality care while advocating for appropriate utilization of health system resources consistent with health plan’s policy, criteria guidelines, and goals.
- Clearly and succinctly documents necessary and/or required information in Utilization Management system.
- Monitors and complies with all state, federal and regulatory requirements relative to accuracy and turnaround times.
- Uses clinical subject matter expertise, as well as knowledge of the interconnection between Utilization Management, claims, and regulatory requirements to respond to complex and/or escalated inquiries.
- Identifies members who could benefit from care management and refers to the appropriate care manager.
- Utilizes critical thinking skills to identify process issues and problems and recommend and/or implement solutions.
- May identify workflow and systems improvements to enhance Utilization Management’s ability to monitor, document and improve key department performance indicators.
- Uses clinical expertise and analytical ability to identify opportunities for new approaches to better address the needs of targeted members, improve outcomes, stakeholder satisfaction, or department effectiveness.
- Maintains caseload volume, complies with contractual requirements regarding turnaround times, and meets department productivity standards.
- Works collaboratively with internal constituents to understand and successfully meet the goals of the department and organization.
- Builds effective external relationships with business partners such as providers, facilities, and vendors to support program effectiveness.
- Uses Utilization Management system platform with proficiency.
- Bachelor’s degree in Nursing or Nursing School Degree with equivalent relevant work experience.
- Minimum 3 years of related experience in an acute care or health insurance environment.
- Minimum 2 years of experience with pre-authorization, utilization review/management, case management, care coordination, and/or discharge planning.
- Bi-lingual preferred.
- Ability to create positive work environment and dynamic with individuals and groups.
- Ability to take action in solving problems exhibiting sound judgement.
- Strong oral and written communication skills; ability to interact within all levels of the organization as well as with external contacts.
- Demonstrates strong organization and time management skills.
- Able to work in a fast-paced environment; ability to multi-task.
- Experience with standard Microsoft Office applications, particularly MS Outlook, Word, Excel and other data entry processing applications.
- Strong analytical and clinical problem-solving skills.
- Ability to work OT during peak periods.