Utilization Management RN PRN Remote

Texas Health Huguley FWS; Altamonte Springs (FL); Remote; USD 60,000 - 100,000; Full time

Job summary

An established industry player is seeking a Utilization Management RN to leverage clinical expertise in patient record analysis. This remote role involves determining the appropriateness of hospital admissions and treatment levels while ensuring compliance with regulatory standards. You will collaborate with multidisciplinary teams to enhance patient care and prevent denial issues. This position offers a chance to thrive in a supportive environment focused on holistic well-being and professional growth. If you are passionate about healthcare and eager to make a difference, this opportunity is perfect for you.

Benefits

Benefits from Day One

Whole Person Wellbeing Resources

Mental Health Resources and Support

Qualifications

• 3+ years of acute care nursing experience required.
• 2+ years of experience in Utilization Management or equivalent.

Responsibilities

• Analyze patient records to determine legitimacy of hospital admissions.
• Facilitate precertification and payer authorization processes.

Skills

Clinical Nursing

Utilization Management

Conflict Resolution

Patient Care Management

Education

ADN or BSN

Bachelor's of Science in Nursing

Tools

Cortex platform

Electronic Health Record

Job description

Job Description

Job Number:

Utilization Management RN PRN Remote (

Job Number:

25012722 )

Description

AdventHealth Corporate

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

1. Benefits from Day One
2. Whole Person Wellbeing Resources
3. Mental Health Resources and Support

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.

Job Location: Remote

The role you will 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 utilizes 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 Utilization Management Nurse is accountable for a designated patient caseload and responsible for specific functions within the role including:

1. Facilitating precertification and payor authorization processes as required, ensuring proper authorization has been secured prior to or at the time of discharge for observation and inpatient stay visits to avoid unnecessary denials.
2. Working in collaboration with facility Care Management to ensure that high quality health care services are provided in a cost-efficient and compliant manner, in line with regulatory standards.
3. Adhering to all rules and regulations of applicable local, state, and federal agencies and accrediting bodies.
4. Actively participating in team workflows and accepting responsibility in maintaining relationships.

The value you will bring to the team:

1. 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.
2. Performs pre-admission status recommendation in Emergency Department or elective procedure settings as assigned, to communicate with providers status guidance based on available information.
3. 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.
4. 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.
5. Works collaboratively and maintains active communication with physicians, nursing and other members of the multi-disciplinary care team to effect timely, appropriate management of claims.
6. Utilizes advanced conflict resolution skills as necessary to ensure timely resolution of issues.
7. 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:
1. Communication to third party payors and other relevant information to the care team;
2. Assignment of appropriate levels of care;
3. Ability to work independently and exercise sound judgment in interactions with physicians, payors, patients and their families;
4. Completion of all required documentation in the Cortex platform and in the system’s electronic health record;
5. Escalating otherwise unresolved status conflicts appropriately and timely to the physician advisor to avoid concurrent denials.
8. Collaborates with medical staff, nursing staff, payor, and ancillary staff to eliminate barriers to efficient delivery of care in the appropriate setting. Communicates with all parties (i.e., staff, physicians, payers, etc.) in a helpful and courteous manner while extending exemplary professionalism. Anticipates and responds to inquiries and needs in an assertive, yet courteous manner. Demonstrates positive interdepartmental communication and cooperation.
9. Actively participates in clinical performance improvement activities.
1. Assists in the collection and reporting of resource and financial indicators including LOS, cost per case, avoidable days, resource utilization, readmission rates, concurrent denials, and appeals.
2. Uses data to drive decisions and plan/implement performance improvement strategies related to care management for assigned patients, including fiscal, clinical, and patient satisfaction data.
3. Collects, analyzes, and addresses variances from the plan of care/care path with physician and/or other members of the healthcare team. Uses concurrent variance data to drive practice changes and positively impact outcomes.
4. Collects delay and other data for specific performance and/or outcome indicators as determined by Director of Care Management.
5. Documents key clinical path variances and outcomes which relate to areas of direct responsibility (e.g., discharge planning). Uses pathway data in collaboration with other disciplines to ensure effective patient management concurrently.

The expertise and experiences you’ll need to succeed:

1. 3+ acute care clinical nursing experience
2. 2+ Utilization Management experience, or equivalent professional experience
3. RN - Registered Nurse - State Licensure and/or Compact State Licensure Current and valid license to practice (ADN or BSN)

Preferred Qualifications:

1. RN licensure at bachelor’s level (or related bachelor’s degree in addition to RN licensure)
2. 5+ Clinical experience in acute care facility
3. 4+ Utilization Management within acute care setting
4. Bachelor's of Science in Nursing – or other related BS or BA in addition to Nursing

Job:

Case Management

Organization:

AdventHealth Corporate

Primary Location:

Work Locations:

CP AH HEADQUARTERS VIRTUAL VIRTUAL Altamonte Springs 32714

Operating Unit: AH Revenue Cycle Services