Behavioral Health Utilization Review Nurse

Overview

Assess and authorize behavioral health services, ensuring medical necessity and compliance.

Key Responsibilities

• utilization review
• compliance monitoring
• prior authorization
• report preparation
• documentation management
• program development

Tasks

-Evaluate and monitor appropriate utilization of resources including durable medical equipment, hospitalizations, and long-term rehabilitation. -Ensure compliance with federal, state guidelines, and contractual requirements. -Serve as a plan liaison to coordinate enrollee benefits with providers and external organizations. -Coordinate with the Medical Director/Physicians for requests outside of standard Review Criteria. -Promote safe and appropriate coordination of care and optimal utilization of resources. -Act as a liaison between the Medical Director, physicians, and office staff to resolve prior authorization questions. -Maintain confidentiality in accordance with company and department policies. -Obtain necessary documentation and ensure completion of assigned caseload. -Review prior authorization requests for medical necessity and appropriateness using standardized Review Criteria. -Provide current and timely documentation reflecting department work processes and policy guidelines. -Prepare and present reports on department activities as assigned. -Identify and participate in the development of programs, policies, and procedures for continuous quality improvement. -Participate in regular departmental training.

Requirements

• rn/lpn
• utilization review
• excel
• emr
• case management
• driver’s license

What You Bring

-Knowledge of case management and utilization review concepts, including InterQual and Milliman Criteria, Florida Medicaid Program and CMS Guidelines. -Current unrestricted Florida RN or LPN License. -Four years of related clinical experience in a healthcare field or equivalent combination of education and experience. -Proficient in word processing software, spreadsheet software such as Microsoft Excel, and electronic medical record software. -Knowledgeable regarding community and post-acute resources and related requirements. -Minimum of one year of utilization review experience and one year of discharge planning experience in an acute care setting. -Valid Florida Driver’s License.

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Benefits

-Mental Health -Time Off/Leave (PTO, Vacation or Sick Leave) -Behavioral Health -Health Spending Account (HSA) -Employee Assistance Program -Life Insurance (Voluntary Life & AD&D for the employee and dependents) -Transportation benefits -Critical Illness, Accident, and Hospital -Medical, dental & vision -Short and long-term disability -401(k) Retirement Plan – Pre-tax and Roth post-tax contributions available

About Actalent

-Born in July 2021 by merging Aerotek’s engineering & sciences arm with EASi, Actalent emerged as a focused engineering-and-science partner. -Backed by Allegis Group, it drives scale and speed to market via contract, managed, and technical services. -Headquartered in Maryland with global reach, it deploys specialized teams across North America, Europe, and APAC on Fortune 500 projects. -Typical engagements span EV design, vaccine development, lab services, clinical research, and infrastructure systems. -Expertise covers a wide spectrum: aerospace, defense, healthcare, manufacturing, software systems, environmental and civil engineering.

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