RN Medical Manager

Universal American is a fast-growing health care company with Medicare Advantage health plans in 48 states.  We have plans to grow through acquisitions and new startup operations in additional markets over the next few years.  This growth and added complexity of our operation is requiring a significant investment in human resources as well and as a result we have a new opening for a RN Medical Manager.

SUMMARY: The RN Medical Manager conducts member reviews ensuring the DME or services that members require are done in a timely manner and comply with the departmental and health plan guidlines.

Responsibilities:Utilization Management policies and procedures and ensuring that the DME or services that members require are done in a timely manner.Collaboration with member’s Providers to get all information required to approve requested item.
Assist in retroactive reviews done for the Claims department.Take calls from members and providers and give them appropriate information to help expedite services.  Conducts Medical Management assistant for telephonic concurrent utilization review. The Care Manager representing the LPO will identify themselves according to the hospitals’ protocol for outside reviewers.  They must remain objective in their review and not participate in anyway in the delivery of care to the patient.Complies with all departmental policies and procedures.  Participates in departmental and company in-services as appropriate.  Performs other duties as assigned by Director.Complies with Customer Service expectations as applicable to the Department and Health Plan.Performs other duties as assigned by Director.

Sarbanes-Oxley Act requirements:

Has direct responsibility for compliance with the Sarbanes-Oxley Act in matters of PHI, and HIPPA . This includes strict adherence to the company’s Business Conduct Statement and Code of Ethics. The emphasis will be on compliance with  protocol, internal controls, and maintaining the highest level of workplace behavior.


Experience/Education: RN with current Texas licensure with at least five years nursing experience in an acute care setting. Two years utilization management experience is an asset.  Bilingual preferred.

Skills:Exhibits basic supervisory skills required to interact with Medical Management assistant. Strong analytical, organizational and time management skills, able to work with little supervision while handling numerous projects at once. Excellent written/verbal communication skills, especially the ability to communicate effectively in stressful situations.  Computer literacy in MS Word / Office. Maintains a valid driver's license for any required facility on-site and home visits.

Please apply online at   http://hostedjobs.openhire.com/epostings/jobs/submit.cfm?fuseaction=dspjob&id=23&jobid=260321&company_id=15763&version=3&source=ONLINE&JobOwner=1002541&level=levelid1&levelid1=24859&parent=Nursing%2FSocial%20Work&startflag=2&CFID=17558491&CFTOKEN=1a70d86-c1aec3a4-fb14-4a9a-b137-33a0ec1c7397.  You can cut and paste this link into your browser. 

No phone calls, email or faxes accepted.  Only individuals who apply online atwill be considered candidates.

 

WE ARE AN EQUAL OPPORTUNITY EMPLOYER