- Perform all types of utilization management (UM) reviews, including but not limited to Pre-service, Post-service, Concurrent Review and Appeals
- Discuss cases with physician providers (Peer to Peer)
- Apply health plan review hierarchy to member contracts, medical policy, clinical guidelines and other approved resources to render timely decisions on medical necessity requests
- Collaborate with Case Managers to provide support and guidance on cases needing physician assistance
- Meet any established metrics (compliance and accreditation) related to UM review efficiency, timeliness, and quality of review
- Participate in ongoing Inter-rater reliability (IRR) audits and any other health plan audits as necessary
- As necessary, assist nurses and other staff in understanding the principles behind appropriate utilization review and interpretation and application of benefits and policies
- Participate in the development and review of Medical and Pharmacy policies as assigned
- Support the organization as a subject matter expert
- Perform as lead Medical Director consultant for one sub-category of utilization management, such as commercial or Medicare medical policy
- Current unrestricted Florida medical license as a Doctor of Medicine or Doctor of Osteopathic Medicine
- Board Certification or Board eligibility by American Board of Medical Specialties or equivalent
- 5+ years' clinical experience
- Experience working in a fast-paced environment
- Experience working both independently and in a team environment
- Physician reviewer or utilization management experience
- Health payor experience
- Primary Care Specialty physician experienc
-
Care Management Assistant
5 days ago
Holy Redeemer Health System Meadowbrook, United StatesHospital Care Management · - Full-Time - Day - 8a-4:30p · Weekend Requirements: None · **SUMMARY OF JOB**:The Care Management Assistant will provide secretarial, clerical and other support to the Care Management Team to ensure that the day to day operational functions of the depa ...
-
Care Manager I
5 days ago
Spectraforce Technologies Jacksonville, United StatesCare Manager I (RN) · 03 months · Compact License · Remote 100% · Licenses/Certifications: · Current state's RN license. · Remote, compact state needed with NY licensure. · Position Purpose: · Perform care management duties to assess, plan, and coordinate all aspects of m ...
-
Care Manager I
4 weeks ago
Spectraforce Technologies Jacksonville, United StatesCare Manager I (RN) · 03 months · Compact License · Remote 100% · Licenses/Certifications: · Current state's RN license. · Remote, compact state needed with NY licensure. · Position Purpose: · Perform care management duties to assess, plan, and coordinate all aspects of medica ...
-
Care Manager I
3 days ago
Spectraforce Technologies Jacksonville, United StatesJob Title: Care Manager I (RN) · Job Location: Remote - (Compact licensure) · Job Duration: 03 Months · Description: · Position Purpose: · Perform care management duties to assess, plan and coordinate all aspects of medical and supporting services across the continuum of care for ...
-
Managed Care Analyst
2 weeks ago
Nemours Jacksonville, United StatesNemours is seeking a Managed Care Analyst (remote) to join our Nemours Children's Health team in Florida or Delaware. · This position provides analytical support to Nemours departments in such areas as Nemours Business Operations, Administration, Strategic Planning, Finance, bot ...
-
System of Care Manager
4 days ago
Lutheran Services Florida Jacksonville, United StatesLutheran Services Florida (LSF) envisions a world where children are safe, families are strong, and communities are vibrant. · LSF is looking for a talentedSystem of Care Manager of SOR and SA Services who wants to make an impact in the lives of others. · The schedule for this ...
-
Clinical Care Manager
3 weeks ago
ChenMed Jacksonville, United States**We're unique. You should be, too.**We're changing lives every day. For both our patients and our team members. Are you innovative and entrepreneurial minded? Is your work ethic and ambition off the charts? Do you inspire others with your kindness and joy?We're different than mo ...
-
System of Care Manager
3 days ago
Lutheran Services Florida Jacksonville, United StatesLutheran Services Florida (LSF) envisions a world where children are safe, families are strong, and communities are vibrant.LSF is looking for a talentedSystem of Care Manager of SOR and SA Services who wants to make an impact in the lives of others.The schedule for this role is ...
-
System of Care Manager
1 week ago
Lutheran Services Florida Jacksonville, United StatesLutheran Services Florida (LSF) envisions a world where children are safe, families are strong, and communities are vibrant . · LSF is looking for a talented · System of Care Manager of SOR and SA Services · who wants to make an impact in the lives of others. · The schedule for t ...
-
Hybrid Patient Care Manager
3 weeks ago
LHC New Jacksonville, United StatesSummary · We are hiring for a Hybrid Patient Care Manager/RN with Home Health experience · At Apex Home Healthcare, a part of LHC Group, we embrace a culture of caring, belonging, and trust and enjoy the meaningful connections that come from it: for the whole patient, their fam ...
-
Patient Care Manager Assistant
3 weeks ago
LHC Group Jacksonville, United StatesJob DescriptionWe are hiring for a Patient Care Manager Assistant (LPN).At Apex Home Healthcare, a part of LHC Group, we embrace a culture of caring, belonging, and trust and enjoy the meaningful connections that come from it: for the whole patient, their families, each other, an ...
-
Hybrid Patient Care Manager
4 weeks ago
LHC Group Jacksonville, United StatesJob DescriptionWe are hiring for a Hybrid Patient Care Manager/RN with Home Health experienceAt Apex Home Healthcare, a part of LHC Group, we embrace a culture of caring, belonging, and trust and enjoy the meaningful connections that come from it: for the whole patient, their fam ...
-
Patient Care Manager Assistant
4 weeks ago
LHC Group Jacksonville, United StatesWe are hiring for a Patient Care Manager Assistant (LPN). At Apex Home Healthcare, a part of LHC Group, we embrace a culture of caring, belonging, and trust and enjoy the meaningful connections that come from it: for the whole patient, their families Patient Care, Care Manager, M ...
-
Hybrid Patient Care Manager
3 weeks ago
LHC Group Jacksonville, United StatesJob Description · We are hiring for a Hybrid Patient Care Manager/RN with Home Health experience · At Apex Home Healthcare, a part of LHC Group, we embrace a culture of caring, belonging, and trust and enjoy the meaningful connections that come from it: for the whole patient, t ...
-
Patient Care Manager Assistant
3 weeks ago
LHC New Jacksonville, United StatesSummaryWe are hiring for a Patient Care Manager Assistant (LPN). · At Apex Home Healthcare, a part of LHC Group, we embrace a culture of caring, belonging, and trust and enjoy the meaningful connections that come from it: for the whole patient, their families, each other, and the ...
-
Hybrid Patient Care Manager
3 weeks ago
LHC New Jacksonville, United StatesSummaryWe are hiring for a Hybrid Patient Care Manager/RN with Home Health experience · At Apex Home Healthcare, a part of LHC Group, we embrace a culture of caring, belonging, and trust and enjoy the meaningful connections that come from it: for the whole patient, their families ...
-
Hybrid Patient Care Manager
3 weeks ago
LHC New Jacksonville, United StatesSummary · We are hiring for a Hybrid Patient Care Manager/RN with Home Health experience · At Apex Home Healthcare, a part of LHC Group, we embrace a culture of caring, belonging, and trust and enjoy the meaningful connections that come from it: for the whole patient, their fami ...
-
Manager RN Care Coordinators
2 weeks ago
Amedisys Inc Jacksonville, FL, United StatesOverview Full Time Day Shift - coverage area is Baker, Clay & St John's counties Are you a highly skilled and compassionate registered nurse (RN) looking for a rewarding career in homecare as a case manager? If so, we invite you to join our team at Amedisys, one of the largest an ...
-
Medical Director Care Management
2 weeks ago
GuideWell Jacksonville, United States· •Perform all types of utilization management (UM) reviews, including but not limited to Pre-service, Post-service, Concurrent Review and Appeals · •Discuss cases with physician providers (Peer to Peer) · •Apply health plan review hierarchy to member contracts, medical policy ...
-
Manager RN Care Coordinators
3 weeks ago
Saint Vincent's Medical Center Riverside Jacksonville, FL, United StatesDepartment: Case Management · * Schedule: PRN · * Hospital: Various health insurance options & wellness plans · Retirement benefits including employer match plans · Long-term & short-term disability · Employee assistance programs (EAP) · Parental leave & adoption assistance · Tui ...
Medical Director Care Management - Jacksonville, United States - GuideWell
Description
Exceptional verbal and written communicationPreferred:
What We Offer:
As a Florida Blue employee, you will thrive in our Be Well, Work Well, GuideWell culture where being well as an individual, and working well as a team, are both important in serving our members and communities.
To support your wellbeing, comprehensive benefits are offered.As an employee, you will have access to:
Medical, dental, vision, life and global travel health insurance;Income protection benefits: life insurance, Short- and long-term disability programs;Leave programs to support personal circumstances;Retirement Savings Plan includes employer contribution and employer match;Paid time off, volunteer time off, 10 holidays and two flexible Well-Being daysAdditional voluntary benefits available; andA comprehensive wellness programEmployee benefits are designed to align with federal and state employment laws.
Benefits may vary based on the state in which work is performed. Benefits for intern, part-time and seasonal employees may differ.To support your financial wellbeing, we offer competitive pay as well as opportunities for incentive or commission compensation. We also conduct regular annual reviews with pay for performance considerations for base pay increases.
Annualized Salary Range:
$216,000 - $351,000
Typical Annualized Hiring Range:
$216,000 - $270,000Final pay will be determined with consideration of market competitiveness, internal equity, and the job-related knowledge, skills, training, and experience you bring.
We are an Equal Opportunity/Protected Veteran/Disabled Employer committed to creating a diverse, inclusive and equitable culture for our employees and communities.