Pre-Certification Review Nurse
Full-Time/Part-Time Full-Time Description
POSITION TITLE: Pre-Certification Review Nurse
JOB NUMBER: 700-023
DEPARTMENT: Utilization Management
REPORTS TO: Supervisor, Clinical
CREATED DATE: December 2013
LAST REVISED: February 2013
GENERAL PURPOSE: The Pre-Certification Reviewer is responsible for the pre-certification of Plan determined procedures utilizing approved criteria.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
- Evaluates requested services following Plan approved criteria.
- Demonstrates effective communication methods and skills, using lines of authority appropriately.
- Establishes a relationship with providers in order to determine/provide needed services for members
- Arranges discharge planning services prior to pre-planned admissions when available.
- Acts as liaison and member advocate between the member/family, physician and facilities/agencies.
- Maintains accurate record of pre-certification decisions.
- Performs decisions within time frames required by regulatory agencies.
- Adheres to quality standards and confidentiality policies and procedures.
- Ensures compliance with all state and federal regulations and guidelines in day-to-day activities.
- Adapts to changes in policies, procedures, new techniques and additional responsibilities.
- Performs other duties as assigned.
QUALIFICATIONS AND REQUIREMENTS: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
EDUCATION and/or EXPERIENCE: Florida licensed RN or LPN required; minimum of two to three years varied clinical experience required; managed care experience preferred; or an equivalent combination of education, training and experience.
NECESSARY KNOWLEDGE, SKILLS AND ABILITIES: Ability to: work from designated office for collaborative/interactive fulfillment of duties; concentrate in an open-office 'cubicle' environment; appropriately and directly interact with other staff members and/or outside associates; perform telephone and/or computer work for extended periods of time; operate office equipment such as computer, telephone, and copy/scan/fax machine; attend and participate in meetings via phone, computer, or in person.
Ability to read and interpret documents and calculate figures and amounts. Excellent oral and written communication skills including good grammar, voice and diction. Proficient in MS Office with basic computer and keyboarding skills. Excellent customer service skills (friendly, courteous and helpful).
LICENSING AND CERTIFICATION: Current Florida licensed RN or LPN required.
PHYSICAL DEMANDS: The physical demands described here are representative of those that should be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this job, the employee is regularly required to sit.
The employee frequently is required to manipulate or use objects, equipment, tools, and/or controls.
May require specific vision abilities to perform this job.
Ability to lift, carry or exert items or objects of reasonable weight.
WORK ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Attendance at employer worksite is an essential job requirement.
The noise level in the work environment is usually moderate.
For the most part ambient room temperatures, lighting and traditional office equipment as found in a typical office environment.
ADDITIONAL INFORMATION: The job description does not constitute an employment agreement between the employer and employee and is subject to change by the employer as the needs of the employer and requirements of the job change.
The duties listed above are intended only as illustrations of the various types of work that may be performed. The omission of specific statements of duties does not exclude them from the position if the work is similar, related or a logical assignment to the position.Position Pre-Certification Review Nurse Position Requirements Req Number NUR-18-00018 Open Date 8/10/2018 AscUDF_OriginalRehireDates_OriginalHireDate None Specified