Utilization Management Nurse Solis Health Plans
Overview
Join Solis Health Plans as a Utilization Management Nurse leading complex medical decisions. You will coordinate care across providers to ensure high quality outcomes while managing resources efficiently. This role offers full benefits and competitive compensation in a growing organization.
What You'll Do11
- 1Conduct concurrent and retrospective utilization review for inpatient observation and SNF services
- 2Perform clinical reviews against criteria to determine medical necessity and benefit eligibility
- 3Collaborate with Medical Directors and provider teams to resolve facility barriers
- 4Identify community resources impacting high-cost care cases
- 5Act as liaison between facilities members and Solis Health Plans
- 6Authorize services and coordinate care ensuring regulatory compliance
- 7Monitor enrollee progress and communicate findings with primary care teams
- 8Advocate for administration exceptions when appropriate
- 9Facilitate discharge planning communication to ensure safe transitions
- 10Review cases with Medical Directors and Primary Care Teams for exception consideration
- 11Maintain accurate documentation and meet CMS time frames
Requirements11
- 1Graduate from accredited nursing school or hold BS/ADN degree
- 2Active unrestricted RN license in Florida
- 3Minimum 3-5 years clinical RN experience
- 42 years Utilization Management nurse experience preferred
- 51 year case management experience highly preferred
- 6Discharge planning experience strongly preferred
- 7Ability to lift up to 10 pounds and occasionally 25 pounds
- 8Frequent speaking hearing visual acuity required
- 9Strong written communication and interpersonal skills
- 10Bilingual English Spanish proficiency required
- 11Commitment to collaborative team environment
Salary Insight
Salary not disclosed in listing
Location
Required Skills
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