Description:
GENERAL SUMMARY
Responsible for the daily supervision of pre-authorization to include the telephone/fax authorization and retrospective claim review processes. Serves in an active managerial role to assist in the development, implementation, and evaluation of the utilization management process.
Current RN license required.
ESSENTIAL RESPONSIBILITIES
- Provides oversight and direction to the staff members including staffing, training, monitoring, and evaluation.
- Reviews the timeliness, appropriateness, and medical necessity of utilization processes performed by the staff. Prepares reports detailing the monitored activities.
- Actively participates in the development, implementation, and oversight of the utilization management activities for the Plan. Serves in an adjunct role for policy and procedure development and implementation.
- Assists in the identification of issues which may adversely impact the attainment of department goals (i.e., telephone answer time, talk time, abandonment rates, etc.).
- Collaborates with other departments to educate providers/vendors and members regarding participating network providers/specialists, benefits and utilization management policies and procedures.
- Attends meetings with internal work groups and external business parties.
- Assists in the identification and reporting of potential quality improvement issues. Responsible for ensuring these issues are reported to the Quality Improvement Department.
- Performs other duties as required.
Qualifications:
JOB SPECIFICATIONS
- Registered nurse with current license in good standing in the state where job functions are performed.
- Bachelor's degree or equivalent experience.
- Previous (usually 2+ years) experience in utilization management.
- Previous (usually 3+ years) experience clinical experience.
- Previous (usually 2+ years) experience supervisory experience.
- Proficiency in medical terminology and ICD-9 and CPT coding preferred.Coventry Health Care is an Affirmative Action/Equal Opportunity Employer, and we are committed to building a talented and diverse team.
Job: Professionals
Primary Location: Tampa, FL, US
Other Locations: ,
Organization: 10000 - Coventry Health Care - Corp
Schedule: Full-time
Job Posting: 2013-11-18 00:00:00.0
Job ID: 1313554
GENERAL SUMMARY
Responsible for the daily supervision of pre-authorization to include the telephone/fax authorization and retrospective claim review processes. Serves in an active managerial role to assist in the development, implementation, and evaluation of the utilization management process.
Current RN license required.
ESSENTIAL RESPONSIBILITIES
- Provides oversight and direction to the staff members including staffing, training, monitoring, and evaluation.
- Reviews the timeliness, appropriateness, and medical necessity of utilization processes performed by the staff. Prepares reports detailing the monitored activities.
- Actively participates in the development, implementation, and oversight of the utilization management activities for the Plan. Serves in an adjunct role for policy and procedure development and implementation.
- Assists in the identification of issues which may adversely impact the attainment of department goals (i.e., telephone answer time, talk time, abandonment rates, etc.).
- Collaborates with other departments to educate providers/vendors and members regarding participating network providers/specialists, benefits and utilization management policies and procedures.
- Attends meetings with internal work groups and external business parties.
- Assists in the identification and reporting of potential quality improvement issues. Responsible for ensuring these issues are reported to the Quality Improvement Department.
- Performs other duties as required.
Qualifications:
JOB SPECIFICATIONS
- Registered nurse with current license in good standing in the state where job functions are performed.
- Bachelor's degree or equivalent experience.
- Previous (usually 2+ years) experience in utilization management.
- Previous (usually 3+ years) experience clinical experience.
- Previous (usually 2+ years) experience supervisory experience.
- Proficiency in medical terminology and ICD-9 and CPT coding preferred.Coventry Health Care is an Affirmative Action/Equal Opportunity Employer, and we are committed to building a talented and diverse team.
Job: Professionals
Primary Location: Tampa, FL, US
Other Locations: ,
Organization: 10000 - Coventry Health Care - Corp
Schedule: Full-time
Job Posting: 2013-11-18 00:00:00.0
Job ID: 1313554