• Job Description

  Req#: 2843

  Job Overview

  This position is responsible for performing duties reviewing patient charts at contracted hospitals and clinics to determine if the quality and utilization of services are within established guidelines.

  Ideal Candidate

  The ideal candidate will have five years experience performing quality assurance, utilization review and clinical case management duties. Knowledge of Federal, State and community resources within Hillsborough County is preferred. The ideal candidate will be bilingual in English and Spanish and have at least three years experience working with Excel and Word. Experience working for a payor/insurance provider is desired.

  Salary

  Min $68,307.20 annually

  Mid $96,740.80 annually

  Core Competencies

  • Customer Commitment - Proactively seeks to understand the needs of the customers and provide the highest standards of service.
  • Dedication to Professionalism and Integrity - Demonstrates and promotes fair, honest, professional, and ethical behaviors that establishes trust throughout the organization and with the public we serve.
  • Organizational Excellence - Takes ownership for excellence through one's personal effectiveness and dedication to the continuous improvement of our operations.
  • Success through Teamwork - Collaborates and builds partnerships through trust and the open exchange of diverse ideas and perspectives to achieve organizational goals.

  Duties and Responsibilities

  Note: The following duties are illustrative and not exhaustive. 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. Depending on assigned area of responsibility, incumbents in the position may perform one or more of the activities described below.

  • Develops and defines policies and procedures related to Quality Assurance and/or Utilization Review.
  • Conducts onsite review of patient charts at contracted hospitals and clinics to determine if guidelines are met.
  • Prepares and submits written findings and corrective action plan recommendations to the Medical Director on non-compliance cases.
  • Advises assigned network staff regarding HealthCare Plan policies and procedures to ensure client needs are met.
  • Assists the Medical Director and Peer Review Committee in the development of Quality Assurance criteria.
  • Performs Disability Determination on assigned cases.
  • Approves the purchase of durable medical equipment and supplies for assigned network clients to ensure quality of care and appropriate use of resources.
  • Conducts special studies as directed by management.
  • Maintains work related records and reports.
  • Attends client appeals as required.
  • Inputs utilization review determinations and related pre-certifications in the computer.
  • Performs medical case management of client within assigned network.
  • Performs other related duties as required.

  Job Specifications

  • Knowledge of nursing theory and practices.
  • Knowledge of general medical and surgical nursing techniques and procedures.
  • Knowledge of the statistical measurement tool (HEDIS) and Quality Assurance indicators.
  • Knowledge of Quality Assurance policies and procedures.
  • Knowledge of the National Committee on Quality Assurance (NCQA) standards.
  • Knowledge of Utilization Review and Case Management policies and procedures.
  • Knowledge of Disability Determination criteria.
  • Ability to collect, organize and evaluate data and to develop logical conclusions.
  • Ability to follow oral and written instruction.
  • Ability to prioritize work.
  • Ability to work effectively with others.
  • Ability to communicate effectively both orally and in writing.
  • Ability to use a computer and related software.

  Physical Requirements

  • This position requires an employee to be able to sit for long periods of time and focus on complicated tasks.

  Work Category

  • Light work - Exerting up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently, and/or a negligible amount of force constantly to move objects. If the use of arm and/or leg control requires exertion of forces greater than that of sedentary work and if the worker sits most of the time, the job is considered light work.

  Minimum Qualifications Required

  • Possession of a valid State of Florida Registered Nurse license; AND
  • Five years of general medical or surgical nursing experience to include two years performing Quality Assurance, Utilization Review or Case Management duties; AND
  • Possession of a valid Florida Driver’s License.

  Emergency Management Responsibilities

  In the event of an emergency or disaster, an employee may be required to respond promptly to duties and responsibilities as assigned by the employee’s department, the County’s Office of Emergency Management, or County Administration. Such assignments may be for before, during or after the emergency/disaster.

  Additional Job Requirements

  A department, depending on the nature of its mission and operations, may require that employees in all or certain positions in this job classification:

  1. Maintain the ability to pass the background checks required for the position. These background checks may include but are not limited to:

  • Criminal History Background Check using Florida Department of Law Enforcement (FDLE) Criminal Justice Information Services (CJIS)
  • Level 1 and Level 2 Background screening (Ch. 435 Florida Statutes)
  • Child Abuse, Abandonment and Neglect Record Check using the State Automated Child Welfare Information System (SACWIS)
  • Sex Offender and Sexual Predator record check using the list maintained by the Florida Department of Law Enforcement (FDLE)

• About the company

  Hillsborough County is a county located in the west central portion of the US state of Florida.

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