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    utilization review care manager- volusia county - Orlando, FL, United States - CareNu

    CareNu
    CareNu Orlando, FL, United States

    3 weeks ago

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    Description
    It's inspiring to work with a company where people truly BELIEVE in what they're doing

    When you become part of the CareNu Team, you'll realize it's more than a job. It's a mission. We're committed to providing groundbreaking solutions for our clients' unique needs offering a wide variety of compassionate healthcare choices. Our employees make all the difference in our success

    Role:
    The Care Manager performs care management duties to assess, plan and coordinate all aspects of medical and supporting services across the continuum of care for select members to promote quality, cost effective care. This position plays a vital role within CareNu.

    Qualifications:
    • Bachelor's degree in Nursing or related field, or an equivalent combination of work experience and education
    • Current Florida license as RN or LPN, current active single-state out-of-state nurse license, or current active multistate/compact nurse license
    • Minimum of two (2) years of clinical nursing experience in a managed care, clinical, acute care, or community setting
    • CCM or other case management certification preferred
    • Demonstrated knowledge of payor contracts and able to provide clinical information to Physicians to ensure cost effective care and metrics standards
    • Previous experience working with an EMR/EHR (Electronic Medical/Health Record) system
    • Proficient computer skills including Excel
    • Ability to effectively communicate in English (verbal and written)
    • Mobile Driver - Valid driver's license and automobile insurance per Company policy
    • Ability to travel to off-site locations
    • Reliable transportation to meet visit schedule
    Competencies:
    • Satisfactorily complete competency requirements for this position.
    Responsibilities of all employees:
    • Represent the Company professionally at all times through care delivered and/or services provided to all clients.
    • Comply with all State, federal and local government regulations, maintaining a strong position against fraud and abuse.
    • Comply with Company policies, procedures and standard practices.
    • Observe the Company's health, safety and security practices.
    • Maintain the confidentiality of patients, families, colleagues and other sensitive situations within the Company.
    • Use resources in a fiscally responsible manner.
    • Promote the Company through participation in community and professional organizations.
    • Participate proactively in improving performance at the organizational, departmental and individual levels.
    • Improve own professional knowledge and skill level.
    • Advance electronic media skills.
    • Support Company research and educational activities.
    • Share expertise with co-workers both formally and informally.
    • Participate in Quality Assessment and Performance Improvement activities as appropriate for the position.
    Job Responsibilities:
    • Develops, assesses and adjusts, as necessary, the care plan and promotes desired outcome. Develops plan of care based upon assessment with specific objectives, goals and interventions designed to meet member's needs. Monitors referrals made to community-based organizations, medical care and other services to support the members' overall care management plan.
    • Performs admission, concurrent and focused reviews applying approved criteria.
    • Performs discharge planning assessment and coordination of subacute care services and benefit enhancements.
    • Assesses the member's current health status, resource utilization, past and present treatment plan and services, prognosis, short and long term goals, treatment and provider options. Coordinates and conducts utilization review activities in accordance with CareNU contracts. Applies Interqual, UniTrust and managed care standards to all utilization review activity and reporting.
    • Performs retrospective reviews or studies following designated guidelines.
    • Coordinates services between Primary Care Physician (PCP), specialists, medical providers, and non-medical staff to meet the complete medical socio-economic needs of clients. Enters and maintains assessments, authorizations, and pertinent clinical information into various medical management systems.
    • Provides education to patients and providers.
    • Facilitates member access to community-based services.
    • Actively participates in integrated team care management rounds.
    • Identifies related risk management quality concerns and reports these scenarios to the appropriate resources.
    • Performs other duties as assigned.
    This position requires consent to drug and/or alcohol testing after a conditional offer of employment is made, as well as on-going compliance with the Drug-Free Workplace Policy.
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