Utilization Management Director jobs in the United States

Applicants must live in Volusia or Flagler Counties to be Considered.

UM department functions 7 days/wk, 365 days/year with a 24/7 on-call nurse. Weekend/holiday rotations and on-call rotations may be required. We currently have nurses working about once every 6-8 weekends.

POSITION SUMMARY:

Under the direction and oversight of the Nurse Supervisor Utilization Management, the Inpatient Utilization Review Nurse is responsible for coordination of services for members of Florida Healthcare Plans admitted to and/or discharged from an inpatient acute or skilled nursing facility as well as outpatient services as delegated. The Inpatient Utilization Review Nurse coordinates all systems/services needed for an organized, multidisciplinary, member focused team approach. The Inpatient Utilization Review Nurse follows and manages the course of treatment for patients while coordinating care with physicians, nurses, case managers, and other staff from outside as well as within the company to ensure quality care and safe outcomes. The Inpatient Utilization Review Nurse conducts initial and ongoing assessments and ensures continuity of care through discharge planning and utilization of resources. Care should be approached in a cost-effective manner as this position bears risk for financial impact to the organization.

QUALIFICATIONS:
Education, skills, and experience:

• Graduate of an accredited school of nursing


• Florida residency is required upon employment.


• Current active and unrestricted licensure in Florida as a Registered Nurse


• An associate degree in nursing is required. Bachelor's degree in nursing preferred.


• Minimum of three (3) years post-licensure hospital clinical experience as a practicing RN. Acceptable areas include but not limited to: Emergency Room, Medical/Surgical, or ICU.


• Previous experience with utilization management, utilization review, prior authorization, or case management is strongly required.


• Knowledge of Medicare criteria, DRG's, InterQual, and/or MCG Care Guidelines is required.


• Knowledge of levels of hospitalization, inpatient rehabilitation, skilled nursing facility, home health care, behavioral health, community resources, and FHCP networks preferred.


• Excellent communication skills, including both oral and written.


• Strong telephone and customer service skills required. Must be able to diffuse difficult situations.


• Strong organizational and time management skills. Must be capable of multitasking.


• Proficiency with computer skills including Microsoft Word, Outlook, and Office Suite


• Must be able to type a minimum of thirty (20) wpm with ninety (90) % accuracy.


• Willing to work an alternate work schedule, occasional weekend/holiday rotation and 24/7 on-call.