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Utilization Management RN FT Days

Company: AdventHealth
Location: Daytona Beach
Posted on: October 14, 2021

Job Description:


Description

Utilization Management RN FT Days

AdventHealth Daytona Beach

Location Address: Daytona Beach, FL - Remote

Top Reasons to Work at AdventHealth Daytona Beach

  • Growing Faith-based organization
  • Great IMMEDIATE benefits such as
  •  Educational Reimbursement
  • Career growth and advancement potential

Work Hours/Shift:

FT / Day - Remote

 

You Will Be Responsible For:

  • 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.
  • Actively participates in clinical performance improvement activities.
  • Ensures requested clinical information has been communicated as requested. Monitors daily discharge reports to assure all patient stay days are authorized. Follows up with insurance carrier to obtain complete authorization to avoid concurrent or retrospective denials. Communicates with the other departments / team members for resolutions of conflicts between status and authorization. Evaluates clinical review(s) and physician documentation for at-risk claims; performs additional reviews and/or include pertinent addendums to fortify/reinforce basis for accurate claim reimbursement. Demonstrates a strong understanding of medical necessity (i.e., severity of illness, intensity of service, risk), level of acuity, and appropriate plan of care.
  • Interacts with physicians, physician office personnel, and/or case management departments on an as-needed basis to assure resolution of pending denials, which have been referred to the physician for peer-to-peer review with the Medical Director of the insurance carrier.
Qualifications

What You Will Need:

  • Current and valid license to practice as a Registered Nurse (ADN or BSN) required.
  • Minimum three years acute care clinical nursing experience required.
  • Minimum two years Utilization Management experience, or equivalent professional experience.
  • Excellent interpersonal communication adn negotiation skill
  • Strong analytical, data management, and computer skills.
  • Strong organizational and time management skills, as evidenced by capacity to prioritize multiple tasks and role components.
  • RN License
  • Bachelor of Science in Nursing – or other related BS or BA in addition to Nursing Preferred
  • Clinical experience in acute care facility – greater than five years Preferred
  • Minimum four years Utilization Management within acute care setting Preferred
  • Experience working in electronic health records of at least two years Preferred

Job Summary:

    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 leverages the algorithmic logic of the XSOLIS Cortex platform, utilizing key clinical data


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

    Keywords: AdventHealth, Daytona Beach , Utilization Management RN FT Days, Other , Daytona Beach, Florida

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