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Licensed Utilization Review Sr PS3020 in Tampa, FL at Anthem, Inc.

Date Posted: 3/13/2018

Job Snapshot

Job Description

Your Talent.  Our Vision.  At Simply Healthcare, a proud member of the Anthem, Inc. family of companies, it’s a powerful combination and the foundation upon which we’re creating greater care for our members, greater value for our customers, and greater health for our communities. We are a Florida licensed health maintenance organization that serves individuals enrolled in Medicaid and/or Medicare programs, Join us and together we will drive the future of health care. This is an exceptional opportunity to do innovative work that means more to you and those we serve.

This position will have the possibility to become telecommute pending overall job performance. Candidate must be located in Tampa, FL.

The Licensed Utilization Review Sr is responsible for working with healthcare providers to help ensure appropriate and consistent administration of plan benefits through collecting clinical information required to preauthorize services, assess medical necessity, out of network services, and appropriateness of treatment setting and applying appropriate medical policies, clinical guidelines, plan benefits, and/or scripted algorithms within scope of licensure. This level works with the most complex elements and requires review of the most complex benefit plans. May also serve as mentor or preceptor for less experienced staff in addition to serving as department representative on various intradepartmental initiatives. May assist in formal training of associates and may be involved in process improvement initiatives within the utilization management function. Examples of such functions may include:

  • Review of claim edits, pre-noted inpatient admissions or, episodic outpatient therapy such as physical therapy that is not associated with a continuum of care, radiology review, or other such review processes that require an understanding of terminology and disease processes and the application of clinical guidelines but do not require nursing judgment.
  • Conducts pre-certification, inpatient, out of network and appropriateness of treatment setting reviews within scope of licensure by utilizing appropriate medical policies and clinical guidelines in compliance with department guidelines and consistent with the members eligibility, benefits and contract.
  • Develops working partnerships with physicians, healthcare service providers, and internal and external customers to help improve health outcomes for members.
  • Applies clinical knowledge to work with facilities and providers for care-coordination.
  • May access and consult with peer clinical reviewers, Medical Directors and/or delegated clinical reviewers to help ensure medically appropriate, quality, cost effective care throughout the medical management process.
  • Educates the member about plan benefits and contracted physicians, facilities and healthcare providers.
  • Refers treatment plans/plan of care to peer clinical reviewers in accordance with established criteria/guidelines and does not issue medical necessity non-certifications.
  • Facilitates accreditation by knowing, understanding, and accurately applying accrediting and regulatory requirements and standards.

Job Requirements

  • Requires an LPN, LVN, or RN; 2 years of clinical or utilization review experience; 2 years of managed care experience and knowledge of the medical management process; or any combination of education and experience, which would provide an equivalent background.
  • Current active unrestricted license in Florida is required.
  • Microsoft Office experience preferred.

Simply Healthcare Plans is a Florida managed health care provider that serves Medicare and Medicaid members. Through our Clear Health Alliance organization, our health plan also serves Floridians who are eligible for HIV/AIDS Medicaid specialty health plan services. Along with our sister plan, Amerigroup Florida, we serve more than 600,000 Floridians who are members of our Medicare and Medicaid plans. Across the nation, our family of health plans serves nearly 40 million members, and 1 in 8 Americans is served by our family of companies. Our health plan members are assured care that is not only accessible, but also accountable, comprehensive, integrated and patient-centered. Each and every day, members of our team can be found in Florida communities, listening to our members, interacting with our health care providers and partnering with community-based organizations to execute health education initiatives. Our goal is to ensure members and entire communities are empowered to become active participants in their health care and sustain healthy lifestyles.


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