This position receives/responds to incoming calls from referral sources/patients and communicates with providers for CareCentrix and contacts referral sources to advise them of referral status. Reviews utilization information concerning patient care for CareCentrix and matches those needs to available care options within the reauthorization guidelines provided by CareCentrix and patients’ health care. Assists the Supervisor and Manager with coaching, training, call monitoring, reports and mentoring of new associates. Acts as a clinical resource to department specialists, providing expertise and clinical knowledge. Negotiates with providers when needed and stay within the guidelines. Performs Utilization Management and participates in performance improvement activities (specific measurement for contracts). Works under moderate supervision.
This position requires excellent communication, customer service and problem solving skills, as well as the ability to effectively interact with all levels of management and a highly diverse clientele. To be successful, the incumbent must be a team player and possess the ability to adapt to multiple changes. Must be able to problem solve difficult situations with internal and external customers. This position requires high level clinical knowledge, communication, customer service and problem solving skills, as well as, the ability to effectively interact with all levels of management and a highly diverse clientele. Must have strong organizational skills and be able to effectively manage and prioritize tasks. Must have a strong commitment to quality and standards. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Ability to negotiate with providers when needed and stay within the guidelines. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.
Associate's Degree or Diploma in Nursing/Practical Nursing or the equivalent and Registered Nurse/LPN/LVN (based on allowable state practice act) license in any state(s) or jurisdiction in the United States is required Expertise in Utilization Management and knowledge of URAC standards. Broad knowledge of health care delivery/managed care regulations, contract terms/stipulations, prior utilization management/review experience, and governmental home health agency regulations required. Excellent negotiation, communication, problem solving and decision making skills also preferred. Required to possess an active license to practice without restrictions. Must have at least 1 year Utilization Management experience.
CareCentrix maintains a drug-free workplace in accordance with Florida’s Drug Free Workplace Law.