Cigna Bilingual Utilization Review RN - Doral, FL in Doral, Florida
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
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
4.Approve requests that fulfill LMCHP and Medicare coverage
guidelines or forwards cases that require additional review to Medical
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
9.Maintain up-to-date clinical knowledge.
10.Perform other related duties assigned.
•Registered Nurse with unrestricted Florida License
•2 or more years of experience in a clinical setting
•Fluency in spoken and written Spanish
•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
Employee Status: Individual Contributor
Job Type: Full-time
Job Level: Day Job
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