Utilization Management RN

adventhealth; Orlando (FL); On-site; USD 68,132 - 119,520; Full time

Benefits offered by this job

Medical Insurance

Dental Insurance

Vision Insurance

Life Insurance

Disability Insurance

PTO (Paid Time Off)

403(b) Retirement Plan

Parental Leave (4 weeks)

Career Development

Well-being Resources

Mental Health Support

Pet Benefits

Job summary

AdventHealth in Altamonte Springs, FL is seeking a registered nurse to join our utilization management team. You will monitor admissions, review medical necessity, and collaborate with a multidisciplinary care team to ensure timely authorizations.

You will use EMR systems to review documentation, handle concurrent and pre-bill denials, and communicate with insurance carriers. A strong focus on interdisciplinary care and patient status alignment is required.

Qualifications

• Associates degree in nursing is required.
• Bachelors degree in nursing preferred.
• 3+ years clinical nursing experience required.
• Experience with utilization management or case management preferred.

Responsibilities

• Monitor admissions and perform initial and continued stay medical necessity reviews.
• Maintain knowledge of payer guidelines and regulatory requirements; manage denials to prevent loss of reimbursement.
• Collaborate with multidisciplinary care team regarding patient status and concurrent denials.
• Build relationships to promote interdisciplinary collaboration.
• Ensure communication of requested clinical information; monitor discharge reports; follow up with insurance for complete authorization.
• Other duties as assigned.

Skills

Clinical Nursing

Case Management

Medical Necessity

EMR

Communication

Education

Associate's Degree in Nursing

Bachelor's Degree in Nursing

Tools

Electronic Health Records

Job description

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.

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

• Benefits from Day One: Medical, Dental, Vision Insurance, Life Insurance, Disability Insurance
• Paid Time Off from Day One
• 403-B Retirement Plan
• 4 Weeks 100% Paid Parental Leave
• Career Development
• Whole Person Well-being Resources
• Mental Health Resources and Support
• Pet Benefits

Schedule: Full time

Shift: Day (United States of America)

Address: 900 HOPE WAY

City: ALTAMONTE SPRINGS

State: Florida

Postal Code: 32714

Job Description:

• Monitor admissions and perform initial and continued stay medical necessity reviews.
• Maintain thorough knowledge of payer guidelines and regulatory requirements and manages concurrent and pre-bill denials to prevent loss of reimbursement.
• Collaborate and communicate with the multidisciplinary care team regarding patient status and concurrent denials.
• Build relationships to promote interdisciplinary collaboration.
• Ensure requested clinical information is communicated, monitors daily discharge reports, and follows up with insurance carriers to obtain complete authorization.
• Other duties as assigned.

Knowledge, Skills, and Abilities:

• Must be able to demonstrate knowledge and skills necessary to provide appropriate status recommendations.
• Demonstrates knowledge of the principles of growth, development, and disease states as it relates to the different life cycles.
• Ability to understand differences between notification, reference, and authorization numbers.
• Maintains up-to-date concurrent authorizations for in-house patients, utilizing daily commercial authorization reports.
• Accesses and reviews payer portals for authorization numbers in collaboration with department assistants; ensures proper update of authorization fields within EMR accordingly, delegating appropriate tasks to support staff.
• Familiarizes self with authorization requirements for assigned payers, based on payer matrix.
• Assists in assuring proper patient status authorization, by reviewing patient admission status within the electronic health record and matching with the correct authorization.
• Expedites communication with insurance contacts to assure timely authorization is received to avoid unnecessary denials.
• Demonstrates working knowledge and understanding of state and federal guidelines pertinent to care management, as well as current procedural terminology (CPT) codes and inpatient-only procedures.
• Ability to provide appropriate status recommendations based on medical necessity indicators, findings, and documentation.
• Navigates and utilizes other related software and databases to perform required actions that encompass Utilization Management.
• Demonstrates strong analytical, problem-solving skills, and the ability to analyze complex data.
• Promotes individual professional growth and development by meeting requirements for mandatory/continuing education, skills competency, supports department-based goals which contribute to the success of the organization; serves as a resource to less experienced staff.
• 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.
• Thorough knowledge of medical admission screening requirements to assist in determining appropriateness of admission, treatment requested, for a variety of conditions, per evidence-based guidelines.
• Knowledge of hospital reimbursement models and trends and their impact.
• Previous experience with and working knowledge of medical necessity screening tool.

Education:

• Associate's of Nursing [Required]
• Bachelor's of Nursing [Preferred]

Schedule:

• Full time days, rotating weekends/holidays

Work Experience:

• 3+ years clinical nursing [Required]
• 5+ years clinical nursing in an acute care setting [Preferred]
• Experience working in electronic health records [Preferred]
• Utilization Management or Case Management [Preferred]

Additional Information:

• N/A

Licenses and Certifications:

• Registered Nurse (RN) [Required]
• Basic Life Support (BLS) [Preferred]
• Accredited Case Manager (ACM) [Preferred] OR Certified Case Manager (CCM) [Preferred]

Physical Requirements:

• Physical Requirements - https://tinyurl.com/msy4mja2

Pay Range: $68,132.50 - $119,520.35

Background Screening Requirement (Florida Law)

Certain positions are subject to Florida Level 2 background screening, including fingerprinting, as required by state law.

Applicants may review general information about Florida’s background screening requirements at Florida Care Provider Background Screening Clearinghouse: https://info.flclearinghouse.com/

This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances.