Job Information

AdventHealth RN Denial Prevention Specialist in Maitland, Florida

Description

YOU ARE REQUIRED TO SUBMIT A RESUME WITH YOUR APPLICATION!

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

  • Benefits from Day One

  • Paid Days Off from Day One

  • Debt-free Education* (Certifications and Degrees without out-of-pocket tuition expense)

  • Sign-on Bonus*

  • Relocation Bonus*

  • Nursing or BU specific benefits and perks

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.

Schedule: Full Time Remote

Shift : 8am - 4:30pm

The community you’ll be caring for:

  • 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.

The role you’ll contribute:

The RN Denial Prevention Specialist will receive daily work assignment from the Team Lead and/or manager to work adjunctively with the Denial Prevention Team to meet deadlines and productivity goals. This RN Denial Prevention Specialist works in collaboration with Pre-Access and HIM, striving to achieve payer authorization and appropriate patient statusing (Inpatient (IP) vs. Observation (OBS) vs. Outpatient (OP)) prior to the performance of identified medical procedures or hospital stays as designated in the team work queue to prevent ‘No Authorization’ denials. The RN Denial Prevention Specialist also reviews the Surgery Schedule across all hospitals within the Central Florida Division South Region for procedures with established high denial rates and risk of Centers for Medicare and Medicaid Services (CMS) non-compliance with Local Coverage Determination (LCD) and National Coverage Determination (NCD), with the goal of ensuring the required documentation is present in the medical record prior to the procedure being performed in order to negate pre-payment and post-payment CMS denials and to help ensure regulatory compliance.

The value you’ll bring to the team:

  • Utilizes software to process clinical information, giving priority to cases with nearest procedure schedule date and/or reimbursement at risk. Processes each pending procedure on the clinical work queue by reviewing available physician documentation in Cerner and/or Athena or other system

  • Pulls surgery schedule for all Central Florida Division South Region facilities as far in advance as necessary to review procedures with established high denial rates and risk of CMS non-compliance with LCD/NCD. Reviews the available records against the LCD/NCD and requests the required documentation from the physician offices through the support staff. Documents action taken in the Utilization Management (UM) section of Cerner.

  • Coordinates with appropriate Pre-Access personnel to initiate the ABN or HINN process in advance of the scheduled procedure when clear contraindication or non-coverage condition exists.

  • Reviews surgery schedule for all Central Florida Division South Region facilities for inappropriate preplanned status for Medicare accounts per CMS Inpatient Only List/C-indicators and documents in the UM section of Cerner Care Manager for the assigned UM Manager to assist with appropriate status management (IP vs. OBS).

  • Utilizes electronic commercial payer authorization websites to enter clinical information and obtain authorization as required. Maintains passwords and access requirements and updates clinical communication in the work queue. Utilizes the Managed Care Payer Matrix and reviews for any updates regarding authorization requirements or other requirements that could alter clinical processes.

Qualifications

The expertise and experiences you'll need to succeed:

EDUCATION AND EXPERIENCE REQUIRED :

  • Graduate of School of Nursing

  • Three years’ experience as RN in an acute clinical setting

  • Bachelor’s or other higher-level degree in the field of nursing, management, or business

EDUCATION AND EXPERIENCE PREFERRED :

  • Master’s or other higher-level degree in the field of nursing, management, or business

LICENSURE, CERTIFICATION, OR REGISTRATION REQUIRED :

  • Current valid State of Florida or multi state license as a Registered Nurse

LICENSURE, CERTIFICATION, OR REGISTRATION PREFERRED :

  • Certification specialty in utilization management, managed care, or other applicable professional certification

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

Category: Patient Financial Services

Organization: AdventHealth Orlando

Schedule: 1 - Day

Shift: AdventHealth Orl Support

Req ID: 22022535

We are an equal opportunity employer and do not tolerate discrimination based on race, color, creed, religion, national origin, sex, marital status, age or disability/handicap with respect to recruitment, selection, placement, promotion, wages, benefits and other terms and conditions of employment.