Registered Nurse Utilization Management - FT/Days at AdventHealth

Date Posted: 5/13/2021

Job Snapshot

  • Job Schedule
    Full-Time
  • Location:
    Maitland, FL
  • Date Posted:
    5/13/2021
  • Job ID:
    21014405
  • Job Family
    Case Management
  • Travel
    No
  • Shift
    1 - Day

Job Description


Description
YOU ARE REQUIRED TO SUBMIT A RESUME, LICENSURE/CERTIFICATION WITH YOUR APPLICATION!

Registered Nurse Utilization Management at AdventHealth Maitland

Top Reasons to work at AdventHealth Maitland 
  • 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.
  • We offer great benefits with immediate Health Insurance coverage
  • Career growth and advancement potential
 Work Hours/Shift:        Full Time / DAY
 
You Will Be Responsible For:   
  • Utilize Utilization Management skills, including a thorough, working knowledge of medical necessity criteria, by the following:
    • Review of admission, level of care, and continued stay information to determine appropriateness of hospital admission status for all payers (inpatient vs. outpatient).
    • Complete a written review/assessment of concurrent denials and report avoidable delays based on the medical records review.
    • Effective communication of clinical information to payers to ensure support of medical necessity/level of care to avoid or reverse a denial.
    • Effective communication to the CM team and clinical team regarding patients not meeting established clinical criteria/standards/guidelines to enable and facilitate timely transfer/discharge to an alternative level of care.
  • Coordinate with CM team when a status change results in a need for patient notification of status change to outpatient observation.
  • Coordinate with CM team for required Medicare discharge appeal related notifications when a patient calls Medicare to appeal their discharge.
  • Utilize software and clinical judgement to prioritize cases at risk for denial, level of care issues, or appropriate status.
  • Ensure appropriate documentation of clinical review summaries maintain the guidelines and standards set by the department.
  • Identify and escalate cases for a second level review to the Physician Advisor for utilization concerns, denial issues, lack of medical necessity, and case resolution.
Qualifications
What Will You Need:        

EDUCATION AND EXPERIENCE REQUIRED:

  • Graduate of School of Nursing (Registered Nurse)
  • Five years’ experience as RN in an acute clinical setting

LICENSURE, CERTIFICATION OR REGISTRATION REQUIRED:

  • Current valid State of Florida or multi-state license as a Registered Nurse
Job Summary:

The Utilization Management (UM) nurse proactively completes case reviews for admission criteria, concurrent utilization of professional services, LOS (length of stay) and criteria for care for all payers.  Works with all members of the UM team to meet deadlines, productivity goals, and performance metrics. Performs review activities and denial management activities as dictated by work flows and payer requests.  Performs chart audits for all regulatory agencies as well as in-house hospital studies.  The UM Nurse works in collaboration with the Physician Advisors, UM Authorization team, Care Management (CM), and the Pre-Access Inpatient team for timely and accurate status and authorization. Supports the campus-wide Care Managers, the physicians and clinical teams in utilization activities and enhancing throughput.  Maintains knowledge of payer guidelines and the Center for Medicare and Medicaid Services (CMS) policies and guidelines to maintain compliance with regulations and to prevent loss of reimbursement.  Participates in process improvement by communicating findings and opportunities for improvement. Adheres to rules and regulations of applicable local, state, and federal agencies. Actively participates in outstanding customer service and accept responsibility in maintaining relationships that are equally respectful to all.


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

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