Medical Policy Manager jobs in Fort Lauderdale, FL

Why work with us?

The North American branch of Generali Global Assistance offers a diverse and inclusive work environment while employees work towards making real difference in the lives of our clients. As an Organization, we pride ourselves with offering white glove service while being mindful of corporate responsibility and our environmental footprint.

Employees enjoy a plethora of benefits to include:

• A diverse, inclusive, professional work environment
• Flexible work schedules
• Company match on 401(k)
• Competitive Paid Time Off policy
• Generous Employer contribution for health, dental and vision insurance
• Company paid short term and long term disability insurance
• Paid Maternity and Paternity Leave
• Tuition reimbursement
• Company paid life insurance
• Employee Assistance program
• Wellness programs
• Fun employee and company events
• Discounts on travel insurance

Who are we?

Generali Global Assistance is proudly part of the Europ Assistance Group brand and our products utilize a number of corporate and product brands. The brands for our North American team include the following:

• CSA: US travel insurance brand for retail and lodging partners. Learn more here.
• Generali Global Assistance (GGA): The primary Corporate brand in the United States for our travel insurance, travel assistance, identity and cyber protection, and beneficiary companion products. Learn more here.
• GMMI: the industry standard for global medical cost containment and medical risk management solutions. Learn more here.
• Iris, Powered by Generali: identity and digital protection solution. Learn more here.
• Trip Mate: US travel insurance brand for tour operator, cruise and airline partners. Learn more here.

What you’ll be doing.

Job Summary:

The Medical Case Manager is a Licensed Practical Nurse or a Registered Nurse who is accountable and capable of securing and reviewing clinical data in order to approve requests for admissions, procedures and services that meet clinical review criteria. Ensures that there is coordination and delegation of care between all providers involved. Ensure that procedures / services are not duplicated and that services being rendered fall within the industry standards of care. The Medical Case Managers responsibilities include but are not limited to: assessment of strengths and weaknesses, implementation of a treatment plan, coordination and availability of resources, familiarity with the insured policy and its’ limitations and the communication and documentation with the appropriate entities that require information as per the stated policies and procedures while adhering to HIPAA and/or GDPR compliance. The Medical Case Manager (UR/UM/CM) is NOT financially incentivized for decisions that result in underutilization, adverse determinations and / or denials.

Principal Duties and Responsibilities:

• Performs UR/UM and Case Management duties according to company policy and procedure.

• Collects client data and conducts emergent and non-emergent clinical assessment.

• Assists in the referral of patients to most appropriate provider specialty / facility within Network.

• Monitors and screens pre-authorization requests for second medical opinion referrals and/or diagnostic testing.

• Reviews hospital admissions for medical necessity and assigns LOS in accordance with established criteria.? Sends out appropriate communication to providers, facilities and/or client.

• Refers all cases that do not fall within pre-established criteria to the Supervisor for further evaluation and determination of admission approval, procedure or services requested or refer to Medical Director or peer reviewer.

• Medical Case Managers do not issue non-certifications (denials). Once it is determined that an admission, procedure or service should be denied; assists in assuring that verbal or written denial notices are distributed out to the appropriate parties in a timely manner.

• Performs duties of the discharge planning nurse to contain LOS and assure that the insured (member/patient) is receiving services within the 6 Rights: Care, Place, Time, Provider, Price and Outcome.

• Assist with the coordination (within all phases) of a repatriation /evacuation and work in accordance to individual Client Procedures as well as internal GMMI Work Instructions and/or Standard Operating Procedures.? Report any change in insureds (member/patient) condition IMMEDIATELY in order to make any differing change in plans.

• Enters and maintains all applicable information related to a case in GMMI’s operating software.

• Attends and participates in all departmental meetings as scheduled. Coordinates data collection and reporting for meetings, as deemed appropriate.

• Evaluates and reviews treatment plan for consistency of care.? Develops realistic treatment plan in conjunction with provider recommendations in order to meet the client’s needs while providing the most appropriate and cost effective method of delivering services.

• Performs written and oral communication with other GMMI staff to provide case information, recommendations based on medical necessity and policy language and cost indexes to clients.

• Evaluates and determines the availability of resources in conjunction with policy limits and coverage. Implements cost management and delivers the most effective treatment plan.

• Maintains current knowledge base with regard to medical-surgical cases, utilization management, discharge planning and continued care needs in relation to physician approved criteria. Case Manager is to expand knowledge base and become familiar with ICD-10 and how it improves cost containment efforts due to specificity.

• Reports concerns, problems, and quality assurance issues with the correct Department Head for further evaluation and possible intervention. Follows up with corrective action on recommendations made when required.

• Responsible for updating the “Tracker” system and for the timely follow up on each case that is monitored in the tracker.

• Participates in issuing non-conformance and corrective actions as per ISO policy when quality issues or disruptions in services or systems are identified (always think proactively).? Mindset: How can I improve the process and / or the outcome

• Functions as a clinical resource to non-clinical staff.

Required / Desired Knowledge, Experiences and Skills:

Requirements:

• Prior to being employed by GMMI, Medical Case Managers need to possess at least two-year experience in the field of Managed Care or related acute care areas; Medical/Surgical, OB/GYN, Pediatrics, Cardiology, Neurology, Nephrology, Orthopedics, Transplant and/or CCU/ICU.

• Maintains confidentiality of all pertinent client/member (patient) information.

• Basic to moderate computer literacy required

• Basic to moderate typing competency required

• Strong organizational and time management skills required – with emphasis on prioritizing and performing multiple tasks in unison.

• Excellent communication skills (verbal and written).

• Effective and sound decision making and problem solving skills a must.

• Ability to work both independently and in a group setting.

• Exercises and displays the ability to interact effectively with physicians, providers, internal staff and insureds’ as deemed necessary.

• Able to work in a multicultural environment and manage a diverse client / patient population is required.

Preferred:

• Bilingual (any language)

Education/Certifications:

Requirements:

• High School Diploma or Equivalent (GED) required.

• Licensed health professionals: LPN or RN. Active license in the state of Florida.

• Keep license current and complete CEU’s as mandated by the Board of Nursing in the state of Florida http://floridasnursing.gov/.

Physical Working Environment:

While performing the duties of this job, the employee is required to stand; walk; sit for long periods of time; use of hands to grasp, handle, or feel; reach with hands and arms; finger dexterity; talk; hear. The employee is occasionally required to climb or balance and stoop, kneel, crouch, or crawl. The employee must frequently lift and/or move up to ten pounds and occasionally lift and/or move up to 25 pounds. Specific vision abilities required by this job include close vision, distance vision, peripheral vision, depth perception and ability to adjust focus.

The above statements are intended to describe the general nature of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all responsibilities, duties and skills required of employees so classified.

Where you’ll be doing it.

This is a hybrid role based out of our Pembroke Pines, FL office. As a hybrid role, you will be working onsite 5 days one week and working from home 5 days the following week (alternating).

When you’ll be doing it.

While there is some flexibility in the hours, this position will be Monday-Friday during regular business hours (approximately 8:00am-5:00pm). Occasional overtime may be required according to business need. On-call weekends may be required.

Apply today to begin your next chapter.

Don’t meet every single requirement? At Generali Global Assistance, we are dedicated to building a diverse, inclusive and enriching workplace, so if you’re excited about this role but your past experience doesn’t align perfectly with every qualification in the job description, we encourage you to apply anyways. You may be just the right candidate for this or other roles.

The Company is committed to providing equal employment opportunity in all our employment programs and decisions. Discrimination in employment on the basis of any classification protected under federal, state, or local law is a violation of our policy. Equal employment opportunity is provided to all employees and applicants for employment without regard age, race, color, religion, creed, sex, gender identity, gender expression, transgender status, pregnancy, childbirth, medical conditions related to pregnancy or childbirth, sexual orientation, national origin, ancestry, ethnicity, citizenship, genetic information, marital status, military status, HIV/AIDS status, mental or physical disability, use of a guide or support animal because of blindness, deafness, or physical handicap, or any other legally protected basis under applicable federal, state, or local law. This policy applies to all terms and conditions of employment, including, but not limited to, recruitment and hiring, classification, placement, promotion, termination, reductions in force, recall, transfer, leaves of absences, compensation, and training. Any employees with questions or concerns about equal employment opportunities in the workplace are encouraged to bring these issues to the attention of Human Resources. The Company will not allow any form of retaliation against individuals who raise issues of equal employment opportunity. All Company employees are responsible for complying with the Company’s Equal Opportunity Policy. Every employee is to treat all other employees equally and fairly. Violations of this policy may subject an employee to disciplinary action, up to and including termination of employment.