Licensed Utilization Review II (RN)

About the position The Licensed Utilization Review II position at Simply Healthcare Plans, Inc., a member of Elevance Health, is a remote role that requires the selected candidate to reside in Florida. This position is integral to ensuring the appropriate and consistent administration of plan benefits by working closely with healthcare providers. The primary responsibilities include collecting clinical information necessary for preauthorizing services, assessing medical necessity, and determining the appropriateness of treatment settings. The role involves applying medical policies, clinical guidelines, and scripted algorithms within the scope of licensure to ensure compliance with department guidelines and member eligibility. In this role, you will conduct various types of reviews, including pre-certification, inpatient, retrospective, and out-of-network reviews. Building relationships with physicians and healthcare service providers is crucial to improving health outcomes for members. You will utilize your clinical knowledge to coordinate care effectively and may consult with peer clinical reviewers and Medical Directors to ensure quality and cost-effective care throughout the medical management process. Educating members about their plan benefits and referring treatment plans to peer reviewers are also key responsibilities. The position may involve leading cross-functional teams and initiatives aimed at process improvement, as well as serving as a liaison to other business areas. The role requires a high level of professionalism and adherence to accrediting and regulatory standards to facilitate accreditation processes. This position operates on a first shift schedule from 8:00 am to 5:00 pm (EST), Monday through Friday, with potential additional hours based on operational needs, including holiday rotations. Responsibilities • Conducts pre-certification, inpatient, retrospective, out of network and appropriateness of treatment setting reviews within scope of licensure. , • Develops relationships with physicians, healthcare service providers, and internal and external customers to improve health outcomes for members. , • Applies clinical knowledge to work with facilities and providers for care-coordination. , • Consults with peer clinical reviewers, Medical Directors, and/or delegated clinical reviewers to ensure medically appropriate, quality, cost-effective care. , • Educates members about plan benefits and contracted physicians, facilities, and healthcare providers. , • Refers treatment plans/plan of care to peer clinical reviewers in accordance with established criteria/guidelines. , • Facilitates accreditation by applying accrediting and regulatory requirements and standards accurately. , • May lead cross-functional teams, projects, initiatives, and process improvement activities. , • May serve as departmental liaison to other areas of the business unit or as a representative on enterprise initiatives. Requirements • Requires a HS diploma or equivalent and a minimum of 2 years of clinical or utilization review experience and minimum of 3 years of managed care experience; or any combination of education and experience that provides an equivalent background. , • Current active unrestricted license or certification as a LPN, LVN, or RN practice as a health professional within the scope of licensure in applicable state(s) or territory of the United States required. Nice-to-haves • Bachelor's degree in nursing is highly preferred. , • Current active unrestricted license or certification as a RN practice as a health professional within the scope of licensure in applicable state of Florida. , • Minimum of 2 years of Long-Term Care clinical or Long-Term Care utilization review experience and minimum of 3 years of managed care experience is strongly preferred. , • Previous Medical Review and/or Prior Authorization/Pre-Certification experience is preferred. , • Certification in the American Association of Managed Care Nurses is preferred. , • Knowledge of the medical management processes and the ability to interpret and apply member contracts, member benefits, and managed care products is strongly preferred. , • Proficient in Microsoft Office. Benefits • Merit increases , • Paid holidays , • Paid Time Off , • Incentive bonus programs , • Medical benefits , • Dental benefits , • Vision benefits , • Short and long term disability benefits , • 401(k) + match , • Stock purchase plan , • Life insurance , • Wellness programs , • Financial education resources Apply Job!