Florida Blue
Published
March 17, 2020
Location
Miami, Florida
Job Type
Work Setting
Remote / Home-based

Description

Job duties include but are not limited to:
• Perform all Federal Employee Program (FEP) utilization management (UM) reviews, including but not limited to Pre-service, Post-service, Concurrent Review and Appeals
• Train and utilize JIVA and all Florida Blue and FEP platforms, applications and tools to best complete needed work and tasks
• Apply FEP review hierarchy to member contracts, medical policy, clinical guidelines and other FEP approved resources to render timely decisions on FEP medical necessity requests
• Collaborate with FEP Case Managers and Review Nurses to provide support and guidance on cases needing physician assistance
• Discuss cases with physician providers (Peer to Peer)
• Meet all established metrics (compliance and accreditation) related to FEP UM review efficiency, timeliness, and quality of review
• Participate in ongoing Inter-rater reliability (IRR) audits and any other health plan audits as necessary
• As necessary, assist nurses and other staff in understanding the principles behind appropriate utilization review, interpretation and application of benefits and policies
• Participate in the development and review of FEP Medical and Pharmacy policies as assigned, and participate with Florida Blue UM department for meetings and development
• Participate with FEP Medical Director, Quality team and other appropriate staff to add clinical expertise to the FEP-focused HEDIS measures as needed
• Participate in developing strategy and interventions to improve HEDIS scores as needed
• Weekend hours (approximately one weekend every 8 weeks for (averaging 4-6 hours per day) are required
• Learn and perform UM reviews for all lines of business (Medicare and Commercial) for weekend calls
• Perform other duties as assigned and needed by the organization

Job Requirements:
• Current unrestricted Florida medical license as a Doctor of Medicine or Doctor of Osteopathic Medicine
• Board Certification by American Board of Medical Specialties or equivalent
• 5+ years of clinical experience
• Experience working in a dynamic, fast-paced environment
• Experience working both independently and in a team environment
• Exceptional verbal and written communication

Preferred Skills:
• Primary Care Specialty physician experience
• Utilization management experience working in a health plan or hospital or with a provider group
• Government insurance experience with UM reviews such as Medicare, Medicaid or FEP

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