Utilization Review Manager at AdventHealth

Date Posted: 10/21/2019

Job Snapshot

  • Job Schedule
  • Job Category
  • Date Posted:
  • Job ID:
  • Job Family
    Care Management
  • Travel
  • Shift
    1 - Day
  • Application Zone
    1-Shared Services
  • Organization
    AdventHealth Fish Memorial

Job Description

Utilization Review Manager AdventHealth Fish Memorial
Location Address: 1055 Saxon Boulevard Orange City, Florida 32763
Top Reasons To Work At AdventHealth Fish Memorial
  • Immediate Health Insurance Coverage
  • Great benefits such as: Educational Reimbursement
  • Career growth and advancement potential
Work Hours/Shift:
  • Full Time Day Shift
You Will Be Responsible For:

o   Manages staff performance by follow on accountabilities, individual meetings, counseling and evaluation.

o   Identifies, implements and evaluates departmental learning needs an facilitates systematic ongoing education according to department needs.

o   Develops and Implements utilization management orientation program, mentoring and development of staff. 

o   Develops ongoing utilization management education for staff.

o   Demonstrates effective communication skills; able to report and convey required information either verbally or written; maintains required level of confidentiality; consults with and/or advises appropriate personnel of situations requiring follow-up interventions.

o   Experience Registered Nurse Care Manager cross-trained with the hospital care management attributes, to include: strong organizational skills, patient –centric care coordination and facilitation, patient advocacy, utilization review/resource management, discharge assessment and planning, and outcomes data management.

o   Supervises, evaluates and or coordinate care management processes/denial prevention, and or denial and appeals management, maintaining regulatory compliance; promote departmental quality improvement initiatives; promote best clinical standards of practices and scope of services for quality patient care and patient safety.

o   Identifies and supports campus goals for utilization management through achieving department metrics with utilization, denials and appeals.  Leads process improvement activities to achieve department goals in cooperation with staff.

o   Oversees with the Director of Care Management the operational and financial aspects of department operations.

o   Applies knowledge of local, state and federal programs to promote necessary utilization and avoid denials.

o   Maintains successful relationships with hospital administration, management, physicians, patients and their families and external providers as appropriate.

o   Performs other duties as assigned or directed to ensure smooth operation of the department.  This includes overseeing coverage of care management functions on temporary basis.

Hospital Denials and Appeals :

o   RAC Audits:

§  Works with the RAC Coordinator in monitoring RAC communication via the Wachovia lockbox.

§  Works in conjunction with the RAC Coordinator to ensure that inpatient RAC audit requests are entered timely into RAC Manager.

§  Oversees RAC audit, appeal, and denial communication.

§  Reviews RAC denials and collaborate with PFS/HIM as needed to determine concurrence with the RAC or an appeal letter to the RAC is indicated; ensuring that appeals are submitted timely as needed for all levels of appeal and that outcomes are entered appropriately.

§  Reports RAC activity at monthly revenue management meetings; maintaining copies of these reports.

§  Reports any identified trends or areas of needed improvement to the Compliance Nurse Manager Auditor.

o   MAC,MIC,PAC, Managed Care, Commercial payer Hospital Denials, Concurrent and Retrospective:

§  Reviews concurrent  and or  retrospective acute care medical necessity denials for concurrence and submit timely appeals or complete status changes as necessary

§  Documents all denials and appeal process in the denial software.

§  Works with the Compliance Nurse Manager Auditor to identify needed educational opportunities for Care Management staff and Physicians.

§  Work with care managers to ensure authorization and certifications of hospital days have been approved by payer; payer information documented in the insurance payer authorization application/software, timely.

§  Work with case managers to ensure clinical reviews are submitted to payer timely for approval for medical necessity continued stay days and avoid a potential non- clinical submission denial;  payer information documented in the insurance payer authorization application/software.

§  Utilize clinical knowledge and experience with disease management and medical services rates, including payer contracts, during the negotiation for a reverse decision of a potential front –end denial.

§  Reports denial activity and reports at monthly revenue management meetings.

§  Provides support/guidance to RN Care Managers regarding concurrent denials and appropriate patient status determinations.

What You Will Need:

•         Minimum 3 years’ experience in an acute care hospital

•         BS in Nursing or related field

•         Three (3) years’ experience as a hospital Care Manager or Utilization Review Nurse

•         Two (2) years’ utilization review, resource management, and denial management experience

•         Current Florida RN license.

Job Summary:

The Manager or Utilization Management  works under the direction of the Director Management to plan, organize, implement and evaluate the utilization management program at Florida Hospital.  This includes Authorizations, Initial Reviews, Concurrent Reviews, Denials and Appeals.   Responsible for review of hospital medical necessity denials, and completes timely submission of all appeals for each level of appeal needed; documents all outcomes appropriately. Responsible for RAC Readiness case review audits, and the tracking of outcomes involving RAC/MAC/MIC/PAC, Commercial Payers, Managed Care, etc. for Florida Hospital Memorial Medical Center (FHMMC) and Florida Hospital Oceanside (FHO). Oversee points of entry access management and front-end denial management processes.  Analyze and monitor metrics to identify trends for process or performance improvement that impact denial rates and reimbursement. Works with the RN care managers, Patient Access, Compliance Nurse Manager Auditor, HIM Staff, CDI staff, Revenue Cycle Team, Care Management Services Physician Advisor (s), Chief Medical Officer and other Medical Staff for educational opportunities to prevent future denials.  Experienced in a supervisory role for utilization review or care management services, managed care services, discharge planning and transitional care planning within a hospital acute care or community –based care setting (s).

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

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