Help us keep patients on the path to the ultimate site of care: home. CareCentrix is committed to making the home the center of patient care.
The core function is to review utilization information concerning patient care for CareCentrix, and to match those needs to available care options, within the CareCentrix guidelines and specific plan payer criteria. Handles verification of all referrals funneled through Triage, verifying information, applying business rules and determining the next steps. Acts as a clinical resource to department care coordinators, providing expertise and clinical knowledge. This position, using clinical expertise, receives/responds to incoming calls from referral sources/potential clients and CareCentrix Care Coordinators and performs administrative assessments of each referral’s appropriateness for CareCentrix services. Researches/identifies all potential payer sources and determines the primary payer. Participates in utilization and quality assessment/improvement activities.
Associate's Degree or Diploma in Nursing/Practical Nursing or the equivalent and a clear and active Registered Nurse/LPN/LVN (based on allowable state practice act) license in any state(s) or jurisdiction in the United States is required. Minimum of 2 years of experience. Broad knowledge of health care delivery/managed care regulations, contract terms/stipulations, prior utilization management/review experience, and governmental home health agency regulations preferred. Excellent negotiation, communication, problem solving and decision making skills also preferred. Excellent knowledge of Utilization Management and URAC standards. Licensed professionals are required to possess a current license to practice without restrictions.
CareCentrix maintains a drug-free workplace in accordance with Florida’s Drug Free Workplace Law.