Actalent is hiring: Utilization Management LPN in Miami

Utilization Management NurseJob DescriptionThe role of the Utilization Management (UM) Nurse is to promote quality, cost-effective outcomes for a population by facilitating collaboration and coordination across settings, identifying member needs, planning for care, monitoring the efficacy of interventions, and advocating to ensure members receive the services and resources required to meet desired health and social outcomes. The UM Nurse is responsible for providing patient-centered care across the care continuum.Responsibilities+ Perform prospective, retrospective, or concurrent medical necessity reviews for an assigned panel of members.+ Review cases for medical necessity and apply the appropriate clinical criteria, including but not limited to Medicare criteria, Medicaid/Medi-cal criteria, Interqual, Milliman, or Health Plan specific guidelines.+ Collaborate with the Medical Director to ensure the integrity of adverse determination notices based on quality standards for adverse determinations.+ Ensure timely and appropriate discharge planning is communicated to the transition of care teams, when applicable.+ Meet or exceed productivity targets set forth.+ Serve as a resource to non-clinical team members when applicable.Essential Skills+ Clinical review+ Utilization management+ Concurrent review+ Utilization review+ Prior authorization+ Health care+ Medicaid+ Medicare+ Milliman commercial guidelines+ InterqualAdditional Skills & Qualifications+ Associate’s degree in Nursing+ Active LVN/LPN license in the state of California+ Minimum 2 years of experience in prospective clinical review/prior authorizations and retrospective review+ Clinical experience in high-acuity areas (med-surg, ED, CCU, ICU, etc.)+ Experience with Medicare and Medicaid clinical reviews+ Working knowledge of MCG and NCQA standards+ Working knowledge of InterQual preferredWork Environment100% onsite in Doral, FL. Shift: Sunday-Thursday, 8am-5pm. Occasional Saturday coverage needed; some flexibility available with supervisor's approval. Candidates with Saturday availability will be given preference due to fluctuating case volumes.About Actalent Actalent is a global leader in engineering and sciences services and talent solutions. We help visionary companies advance their engineering and science initiatives through access to specialized experts who drive scale, innovation and speed to market. With a network of almost 30,000 consultants and more than 4,500 clients across the U.S., Canada, Asia and Europe, Actalent serves many of the Fortune 500. Diversity, Equity & Inclusion At Actalent, diversity and inclusion are a bridge towards the equity and success of our people. DE&I are embedded into our culture through:+ Hiring diverse talent+ Maintaining an inclusive environment through persistent self-reflection+ Building a culture of care, engagement, and recognition with clear outcomes+ Ensuring growth opportunities for our peopleThe company is an equal opportunity employer and will consider all applications without regard to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.If you would like to request a reasonable accommodation, such as the modification or adjustment of the job application process or interviewing process due to a disability, please email actalentaccommodation@actalentservices.com (%20actalentaccommodation@actalentservices.com) for other accommodation options.