Senior Project Manager
Just In Time Group
Job type full-time
Full job description
This psoition serves as florida blue medicare's clinical expert in working with providers, facilities and subscribers in overseeing the well being of subscribers while ensuring the proper administration of benefits, cost effectiveness, and the coordination of the delivery of quality care.
The essential functions listed represent the major duties of this role, additional duties may be assigned.
Review and resolve complex processing issues and utilization management cases, ensuring accurate and timely medical review processing of designated pre-service healthcare services
Responsible for more complex review requestsReview and authorize, as appropriate, phone/fax referral/authorization and clinical form requests to determine benefit coverage and medical necessity per established criteria meeting compliance standards and timeframes
Process pre-service medical review requests received via phone following internal policies and procedures accurately, timely and with attention to detail
Research requests not clearly meeting established criteria
Conduct review of subscriber's medical information in order to ensure appropriate benefit administration.
Abstract clinical case presented, review cases and potential denials with the medical directors
Coordinate and maintain complete written documentation on all prior authorizations requests.
Provides world class telephone customer service to plan members and/or providers by answering benefit questions, researching and resolving issues and inquiries and ensuring members and providers understand the company’s products and services
Conduct training of new staff members and providers as needed.
Required work experience
3+ years related work experienceExperience details: combined experience in utilization management, case management, home health and clinical
Required licenses and certifications
Rn - registered nurse - state licensure and/or compact state licensure florida license, unrestricted
Additional required qualifications
1 year utilization management experience
Excellent planning, organizational skills
Excellent verbal and written communication skills
Ability to work independently
Ability to handle multiple tasks
Decision making skills
Flexibility additional preferred qualifications
• basic pc knowledge • managed care experience, including interqual • understanding of regulatory agencies • medicare advantage experience general physical demands
Sedentary work: exerting up to 10 pounds of force occasionally to move objectsJobs are sedentary if traversing activities are required only occasionally.
We are an equal opportunity employer/protected veteran/disabled.