Nursing Opportunites: AvMed Health Plans

Weekend Reviewer – 09N035 – Miami (email: HRjobs.south@avmed.org)

SCOPE OF POSITION:

The Weekend Inpatient Case Manager will support the Medical Department with follow up on all potential discharge cases for the weekend and coordination of care. Performs telephonic concurrent utilization review on all assigned hospitalized Members utilizing Milliman Guidelines. Reports clinical information to the Utilization Management. Works with providers to assist with the coordination of benefits of our members. Coordinates and discuss alternative care requests from the attending physicians' offices/panelists, appropriate hospital staff (i.e., discharge planner, social worker, utilization review nurse), ancillary providers, or AvMed Utilization Review staff. The ICM will coordinate the care and services of selected Member populations across the continuum care; promotes effective utilization and coordinates health care resources. The ICM will be responsible for working with the physician, AvMed Pre-Authorization, Disease Management or other Case Management programs, Concurrent Review staff, and the Member and/or family to promote quality care that is delivered in the most appropriate setting. Identification and services arranged to members needing coordination for discharge needs. The ICM will work closely with the Manager to assess, plan, implement, coordinate, monitor, and evaluate services and outcomes to maximize the benefit for the Member. The overall impact of the role of the ICM is to promote continuity of care, to assist the Member in overcoming any barriers to care and to promote Member satisfaction. Recognizes and observes all company and departmental policies and procedures. Focuses on achieving departmental and organizational objectives. Maintains professional appearance by complying with dress code in an appropriate manner.

QUALIFICATIONS:

Registered Nurse with current Florida license. Five (5) years acute care experience. Must have Managed care experience. Home health, Rehabilitation, and/or discharge planning experience. Ability to work independently with minimal supervision. Able to work closely with other team members.

AvMed Health Plans is a Drug/Tobacco-Free Workplace, EOE.

Supervisor, Medicare Risk Optimization – 09S035 – Miami (email: HRjobs.south@avmed.org )

SCOPE OF POSITION:

Supervise the Retrospective Review Department’s Medicare Risk Optimization staff by handling the day-to-day operations for the following functions. Completion of retrospective reviews of suspected clinical condition(s), including internal and external components. Prospective New Enrollee contacts to ensure capture and validation of member reported conditions. Administrative support related to Medicare Risk Optimization. Monitor and track timeliness and accuracy of internal reviews to evaluate and capture suspect conditions generated by Plan Data Management application/Health Plan. Review and decide on the appropriateness of recommendations for external reviews when a suspect condition cannot be satisfied by the internal review process, but is deemed highly probable based on Clinicians judgment. Oversees New Enrollee Health Status Survey function to ensure timely contact, identification, validation and follow-up of member reported conditions. Supervise Administrative Reviewer to assure accurate and comprehensive data entry for data collected from the prospective, as well as internal and external review(s) related to the Medicare Optimization Function. Conduct/ supervise external fields reviews when warranted. Maintain excellent working relationships with internal and external customers. Recognizes and observes all company and departmental policies and procedures. Support Department Manager on achieving departmental and organizational objectives. Conduct timely Performance Appraisal reviews. Assist with employee Disciplinary Action. Assist in developing job descriptions, procedures, and workflows. Focus on achieving departmental and organizational objectives. Act as an AMISYS, Casetrakker, and MACESS Super user.

QUALIFICATIONS:

Registered Nurse with current Florida license. 3-5 years of clinical experience with acute and medical-surgical clinical background. Medical Terminology required. Prior Supervisory Experience strongly preferred. Basic tying skills required. Advanced ability to perform internet-based research required. Working knowledge of Microsoft Excel required. Working knowledge of Microsoft Word experience required Milliman/InterQual knowledge required. Coding knowledge required (HCPCS, CPT, ICD9). Provider billing knowledge preferred. Knowledge of Managed Care contracting methodologies preferred. AMISYS knowledge preferred.

AvMed Health Plans is a Drug/Tobacco-Free Workplace, EOE.

Supervisor, Utilization Management – 09S030 – Miami (email: HRjobs.south@avmed.org )

SCOPE OF POSITION:

To support the Manager of Utilization Management, Medical Directors', and UM staff in achieving clinical and service driven objectives by assisting in coordination of care issues for our members'. Assist with the management of the Utilization Management Program ensuring objectives and goals of the department are carried out to achieve the desired outcomes. Act as a liaison between the Utilization Management staff, UM Manager, and Medical Directors in reporting, identifying specific problems, and offering strategic ideas for improvement regarding the Utilization Management Program. Provide coverage for the UM Staff as needed by providing clinical support. Work closely with the Medical Support Service department to reflect UM Compliance on UM issues and the denial process. Provide coverage for UM Manager as needed. Coordinate utilization review report from the Inpatient Case Managers for discussion with Medical Director and/or UM Manager. Oversee utilization review for all hospitalized members at each level of care. Participates in the interviewing process to assess qualification and feedback for tentative new staff members for the UM department focusing on core values of the company.

QUALIFICATIONS:

Registered Nurse with a current Florida license. Supervisory or management experience in a managed health care setting. Five years of acute clinical/surgical experience, current experience in Utilization Management to include Pre-Authorization, Utilization Review, Concurrent Review, Discharge Planning, Skilled Nursing Facility reviews and Complex Case Management. Three to five years of previous HMO experience. Analytical. Good problem solving skills. Able to function well under stress. Demonstrate excellent verbal and written communication skills. Demonstrate effective critical thinking and decision making skills.

AvMed Health Plans is a Drug/Tobacco-Free Workplace, EOE.