Utilization Management RN

Case Management Society of America (CMSA) ®; Orlando (FL); Remote; USD 70,000 - 85,000; Full time

Job summary

Une organisation de soins de santé de premier plan recherche un Utilization Management Registered Nurse (RN) pour rejoindre son équipe dynamique. Dans ce rôle, vous utiliserez votre expertise clinique pour analyser des dossiers de patients dans un environnement de travail collaboratif. Avec un engagement envers l'amélioration de la qualité des soins, vous contribuerez à des recommandations critiques concernant les soins des patients tout en naviguant dans les processus d'autorisation de paiement. Si vous êtes passionné par l'amélioration des soins aux patients et avez l'expérience requise, nous vous encourageons à postuler.

Benefits

Bénéfices dès le premier jour

Éducation sans dettes (Certifications et diplômes sans frais de scolarité hors poche)

Qualifications

• Actuellement titulaire d'une licence d'infirmier autorisé en Floride.
• Minimum de trois ans d'expérience clinique en soins aigus requis.
• Expérience en gestion de l'utilisation de deux ans ou équivalent.

Responsibilities

• Analyser les dossiers des patients pour déterminer la légitimité des admissions à l'hôpital et des niveaux de soins.
• Documenter les résultats selon les normes du département et réglementaires.
• Collaborer avec les médecins et les membres de l'équipe de soins.

Skills

Communication interpersonnelle

Analyse de données

Compétences en négociation

Gestion du temps

Education

ADN ou BSN en soins infirmiers

Baccalauréat en sciences infirmières

Job description

All the benefits and perks you need for you and your family:

· Benefits from Day One

· Paid Days Off from Day One

· Debt-free Education* (Certifications and Degrees without out-of-pocket tuition expense)

Our promise to you:

Joining AdventHealth is about being part of something bigger. It’s about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit. AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding that together we are even better.

Schedule: Full Time Remote, Applicant must live within a 50-mile radius or be a current employee within an AdventHealth region.

Shift : Monday – Friday, 8am - 4:30pm, every 4 th weekend, may vary based on business needs.

The community you’ll be caring for:

• The Maitland Office Plaza houses our highly skilled teams that support our hospital system including Marketing, Patient Financial Services, Revenue Management, the Credit Union and Human Resources.
• The Trickle Building, a two-story office structure, creates an atmosphere of health and healing, with a healthy-style café and quaint chapel.
• The main lobby is filled with lush greenery and a light trickle of water, creating a holistic environment.

The role you’ll contribute:

The role of the Utilization Management (UM) Registered Nurse (RN) is to use clinical expertise by analyzing patient records to determine legitimacy of hospital admission, treatment, and appropriate level of care. The UM RN leverages the algorithmic logic of the XSOLIS Cortex platform, utilizing key clinical data points to assist in status and level of care recommendations. The UM RN is responsible to document findings based on department and regulatory standards. When screening criteria does not align with the physician order or a status conflict is indicated, the UM nurse is responsible for escalation to the Physician Advisor or designated leader for additional review as determined by department standards. Additionally, the UM RN is responsible for denial avoidance strategies including concurrent payer communications to resolve status disputes.

The value you’ll bring to the team:

• Monitors admissions and performs initial patient reviews within 24 hours of admission; and when warranted by length of stay, utilization review plan, and/or best practice guidelines, on a continuing basis.
• Performs pre-admission status recommendation in Emergency Department or elective procedure settings as assigned, to communicate with providers status guidance based on available information.
• Maintaining thorough knowledge of payer guidelines, familiarity with payer processes for initiating authorizations, and following through accordingly to prevent loss of reimbursement, including the management of concurrent and pre-bill denials.
• Ensuring all benefits, authorization requirements, and collection notes are obtained and clearly documented on accounts in the pursuit of timely reimbursement within established timeframes to avoid denials.
• Works collaboratively and maintains active communication with physicians, nursing and other members of the multidisciplinary care team to effect timely, appropriate management of claims.
• Utilizes advanced conflict resolution skills as necessary to ensure timely resolution of issues.
• Collaborates with the physician and all members of the multidisciplinary team to facilitate care for designated case load; monitors the patient's progress, intervening as necessary and appropriate to ensure that the plan of care and services provided are patient focused, high quality, efficient, and cost effective; facilitates the following on a timely basis:
• Communication to third party payors and other relevant information to the care team;
• Ability to work independently and exercise sound judgment in interactions with physicians, payors, patients and their families;
• Completion of all required documentation in the Cortex platform and in the system's electronic health record.

Qualifications

The expertise and experiences you'll need to succeed:

EDUCATION AND EXPERIENCE REQUIRED:

• Current and valid license to practice in Florida as a Registered Nurse (ADN or BSN) required.
• Minimum three years acute care clinical nursing experience required.
• Minimum two years Utilization Management experience, or equivalent professional experience.
• Excellent interpersonal communication and negotiation skill.
• Strong analytical, data management, and computer skills.
• Strong organizational and time management skills, as evidenced by capacity to prioritize multiple tasks and role components.

PREFERRED:

• Bachelor of Science in Nursing – or other related BS or BA in addition to Nursing
• Clinical experience in acute care facility – greater than five years
• Minimum four years Utilization Management within acute care setting
• Experience working in electronic health records of at least two years

REGISTRATION REQUIRED:

• Registered Nurse

This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances. The salary range reflects the anticipated base pay range for this position. Individual compensation is determined based on skills, experience and other relevant factors within this pay range. The minimums and maximums for each position may vary based on geographical location.

Category: Case Management

Organization: AdventHealth Orlando

Schedule: Full-time

Shift: 1 - Day

Req ID: 25023817

We are an equal opportunity employer and do not tolerate discrimination based on race, color, creed, religion, national origin, sex, marital status, age or disability/handicap with respect to recruitment, selection, placement, promotion, wages, benefits and other terms and conditions of employment.