• Florida

Health Choice Network - VBS - Utilization Management Specialist

Health Choice Network is committed to provide exceptional customer service that exceeds the expectation of those we service. Each and every employee at HCN is expected to possess the ability to inspire confidence, display a constructive attitude, make ethical business decisions, and represent the company well in all aspects of customer service.

Position Purpose:

The Utilization Management Specialist will assess, plan, coordinate, monitor and evaluate options to facilitate appropriate healthcare services to assigned patients. This position is responsible for identifying opportunities and services needed to ensure proper management and documentation of patients' health profile.

Job Responsibilities:

  • Performs assessment of overall contract performance and identifies areas of targeted utilization management review.

  • Monitors and trends resource utilization and cost management practices on a monthly, quarterly, and annual basis.

  • Advises on cost effective alternative practices or solutions that will improve performance at a network, center, and provider level while ensuring standards of care are met.

  • Conducts a comprehensive assessment of the patients' current health status including physical, psychological, environmental, financial, and health status.

  • Provides guidance and interpretation on issues of medical appropriateness, benefit application as appropriate, and level of care necessary

  • Reviews centers' documentation practices, provides direct provider feedback, and advises practices to ensure accurate and comprehensive assessments of patients care are documented and coded.

  • Collaborates with health plans to ensure appropriate resources are coordinated and utilized.

  • Creates and maintains a comprehensive inventory of local community and government resources for centers to provide to patients and facilitates the patient's access to these resources

  • Implements and monitors transitions of care programs steaming from hospital admissions and emergency room discharges.

  • Collaborates internally with quality, value based services and research teams on strategic initiatives focused on enhancing the quality and value of care provided by our centers.

  • Performs other duties as assigned.

Education, Experience and Certifications:

  • RN or Foreign Medical Graduate with a Bachelor's degree from four-year college or university; or one to two years related experience and/or training; or equivalent combination of education and experience.

  • One year of experience in case management or utilization management with knowledge of payer mechanisms and utilization management is preferred.

  • Certified Professional Utilization Reviewer (CPUR) preferred.

  • ECFMG, RN or LPN license is required