Utilization Management RN PRN Remote

AdventHealth; Altamonte Springs (FL); Remote; USD 65,000 - 95,000; Full time

Job summary

An established industry player is seeking a dedicated Utilization Management Registered Nurse to join their dynamic team. This role offers the opportunity to leverage your clinical expertise in a remote setting, analyzing patient records to ensure appropriate levels of care and facilitating seamless communication between healthcare providers. You'll play a crucial role in preventing denials and ensuring high-quality patient care while working collaboratively with a multidisciplinary team. If you're passionate about making a difference in patient outcomes and thrive in a supportive environment, this position is perfect for you.

Benefits

Benefits from Day One

Career Development

Whole Person Wellbeing Resources

Mental Health Resources and Support

Qualifications

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

Responsibilities

• Analyze patient records to determine the legitimacy of hospital admissions.
• Collaborate with multidisciplinary teams to ensure timely claims management.

Skills

Clinical Nursing

Utilization Management

Conflict Resolution

Patient Care Coordination

Education

Registered Nurse Licensure

Bachelor's of Science in Nursing

Tools

Cortex Platform

Electronic Health Record Systems

Job description

AdventHealth Corporate

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

· Benefits from Day One

· Career Development

· Whole Person Wellbeing Resources

· 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.

Shift : Per-diem, PRN days, required two weekend days per month

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: 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. 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. Adhering to all rules and regulations of applicable local, state, and federal agencies and accrediting bodies. Actively participating in team workflows and accepting responsibility in maintaining relationships

The value you will 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 multi-disciplinary 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; * Assignment of appropriate levels of care; * 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; * Escalating otherwise unresolved status conflicts appropriately and timely to the physician advisor to avoid concurrent denials.

· 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.

The expertise and experiences you’ll need to succeed:

· 3+ acute care clinical nursing experience

· 2+ Utilization Management experience, or equivalent professional experience

· RN - Registered Nurse - State Licensure and/or Compact State Licensure Current and valid license to practice (ADN or BSN)

Preferred Qualifications:

· Accredited Case Manager (ACM)

· CCM - Certified Case Manager

· RN licensure at bachelor’s level (or related bachelor’s degree in addition to RN licensure)

· 5+ Clinical experience in acute care facility

· 4+ Utilization Management within acute care setting

· Bachelor's of Science in Nursing – or other related BS or BA in addition to Nursing