Cigna Bilingual Utilization Review RN - Doral, FL in Doral, Florida

Description:

Job Title: Bilingual Utilization Review Nurse

Job Summary: To review requests for coverage of outpatient and inpatient

medical services, request additional clinical information as needed,

review applicable coverage guidelines, approve services that meet

established criteria or forward requests to medical director for

secondary review.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

1.Review requests for medical services that require prior

authorization as per LMCHP/Medicare guidelines and timeframes, including

both outpatient and inpatient services.

2.Contact requesting providers to obtain additional information

when needed to establish medical necessity.

3.Might conduct on-site concurrent reviews at inpatient

hospitals/units, to establish medical necessity of services being

rendered.

4.Approve requests that fulfill LMCHP and Medicare coverage

guidelines or forwards cases that require additional review to Medical

Director

5.Answer telephonic inquiries from medical directors and providers

regarding the status of organization determinations.

6.Maintain open channels of communication with requesting

providers, attending physicians and business partners.

7.Comply with Leon Medical Centers Health Plans, Medicare and State

policies and procedures and maintain confidentiality of member

information in accordance with state and federal laws.

8.Participate in mandatory trainings and competency testing as

required.

9.Maintain up-to-date clinical knowledge.

10.Perform other related duties assigned.

Qualifications:

QUALIFICATIONS:

Required:

•Registered Nurse with unrestricted Florida License

•2 or more years of experience in a clinical setting

•Fluency in spoken and written Spanish

Preferred:

•One or more years of experience in utilization review

•Extensive knowledge of Medicare guidelines

•Bachelor’s level education

Primary Location: Doral-Florida

Work Locations: 8600 NW 41st St. Doral 33166

Job: Med Mgt--Utilization Mgmt

Schedule: Regular

Shift: Standard

Employee Status: Individual Contributor

Job Type: Full-time

Job Level: Day Job

Travel:

Job Posting: Dec 6, 2018, 11:30:18 AM

Qualified applicants will be considered for employment without regard to age, race, color, religion, national origin, sex, sexual orientation, gender identity, disability, veteran status. Need an accommodation? Email: SeeYourself@cigna.com