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Utilization Management Coordinator RN - Manager
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Full-time
- Under the general supervision of the Director of Health Services, the position is responsible for appropriately and successfully executing clinical and administrative health plan denials in accordance with regulatory guidelines and plan policies.
- Is responsible for managing all denials by conducting a comprehensive review of clinical documentation, clinical criteria/evidence-based guideline, policy, and or EOC/benefit policy.
- Processes Medical Director or Behavior Health Practitioner denials in accordance with regulatory guidelines and plan policies.
- Formulates a clear and concise clinically based or administrative argument to denial rationales supported by clinical criteria, including but not limited to, CMS, Florida Medicaid, CFR, Health Plan, InterQual (IQ), Milliman Care Guidelines (MCG), and UpToDate.
- Complies with company and department policies and procedures to ensure timely and denials.
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