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.
A current RN license is required for this position.
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: 2013-05-20 00:00:00.0
Job ID: 1311786
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.
A current RN license is required for this position.
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: 2013-05-20 00:00:00.0
Job ID: 1311786