Healthcare Services Review Nurse

Wherever and however Hillsborough County fits into your career path, our belief stays the same: don’t just work somewhere, work somewhere you have the ability to create community prosperity.

Hillsborough County, Florida

Hillsborough County

A great place to live, work and play.

keywords: environment,teamwork,tuition reimbursement,medical,patient charts,network,management,communication,reporting,purchasing,education,nurse

Full Time

$46,238.40 - $73,424.00/year

Overview: <ul> <li><strong>Success through Teamwork</strong>: Collaborates and builds partnerships through trust and the open exchange of diverse ideas and perspectives to achieve organizational goals.</li> <li> <p><strong>Work Environment:&nbsp;</strong>Frequently in a normal office situation. Occasionally in a high noise environment. Occasionally requires extensive safety training and/or protective devices. Occasionally requires travel, excluding overnight stays. Occasionally exposed to weather including heat, cold, dampness and/or humidity</p> </li> <li><a href="" target="_blank">Check out our awesome benefits here</a></li> </ul>
Responsibilities: <ul> <li>Oversees the Medical Management Vendor, develops and defines policies and procedures, and ensures program effectiveness as it relates to Medicare Compliance, Quality Assurance and/or Utilization Review. &nbsp;</li> <li>Conducts review of patient charts at contracted hospitals and clinics to determine if guidelines are met for select cases, where emergent enrollment is requested and for other cases requiring clinical judgment at the RN level. &nbsp;</li> <li>Prepares and submits written findings and corrective action plan recommendations to the Division Director, Medical Management Vendor's Medical Director on non-compliance cases or those requiring a physician review. &nbsp;</li> <li>Advises assigned network staff regarding HealthCare Plan policies and procedures to ensure client needs are met. &nbsp;</li> <li>Assists the Network Medical Directors and HCAB Medical Subcommittee in the development of Quality Assurance criteria. &nbsp;</li> <li>Assists in identifying cases that may qualify for disability using Medicare criteria.</li> <li>Approves the purchase of durable medical equipment and supplies for assigned network clients to ensure quality of care and appropriate use of resources consistent with Medicare guidelines. &nbsp;</li> <li>Conducts special utilization studies as directed by management. &nbsp;</li> <li>Maintains work related records and reports where necessary.</li> <li>Inputs utilization review determinations and related pre-certifications in the computer. &nbsp;</li> <li>Performs medical case management of client within assigned network. &nbsp;</li> <li>Performs other related duties as required.</li> </ul>
Requirements: <ul> <li>Graduation from high school or GED certificate</li> <li>Possession of a valid State of Florida Registered Nurse license; <strong>and&nbsp;</strong>Five years of general medical or surgical nursing experience to include two years performing Quality Assurance, Utilization Review or Case Management duties; <strong>and&nbsp;</strong>Possession of a valid Driver License. &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;</li> <li><strong><strong>Or </strong></strong>an equivalent combination of education, training, and experience that would reasonably be expected to provide the job-related competencies noted below.</li> </ul>