Utilization Management RN EX

About the role

Maintain thorough knowledge of payer guidelines and regulatory requirements and manages concurrent and pre-bill denials to prevent loss of reimbursement.

Collaborate and communicate with the multidisciplinary care team regarding patient status and concurrent denials.

Build relationships to promote interdisciplinary collaboration.

Ensure requested clinical information is communicated, monitors daily discharge reports, and follows up with insurance carriers to obtain complete authorization.

Responsibilities

• Monitor admissions and perform initial and continued stay medical necessity reviews.
• Collaborate and communicate with the multidisciplinary care team regarding patient status and concurrent denials.
• Build relationships to promote interdisciplinary collaboration.
• Ensure requested clinical information is communicated, monitors daily discharge reports, and follows up with insurance carriers to obtain complete authorization.
• Expedites communication with insurance contacts to assure timely authorization is received to avoid unnecessary denials.
• Assists in assuring proper patient status authorization, by reviewing patient admission status within the electronic health record and matching with the correct authorization.
• Accesses and reviews payer portals for authorization numbers in collaboration with department assistants; ensures proper update of authorization fields within EMR accordingly, delegating appropriate tasks to support staff.
• Familiarizes self with authorization requirements for assigned payers, based on payer matrix.
• Provides appropriate status recommendations based on medical necessity indicators, findings, and documentation.
• Navigates and utilizes other related software and databases to perform required actions that encompass Utilization Management.
• Demonstrates strong analytical, problem-solving skills, and the ability to analyze complex data.
• Promotes individual professional growth and development by meeting requirements for mandatory/continuing education, skills competency, supports department-based goals which contribute to the success of the organization; serves as a resource to less experienced staff.
• Excellent interpersonal communication and 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.
• Thorough knowledge of medical admission screening requirements to assist in determining appropriateness of admission, treatment requested, for a variety of conditions, per evidence-based guidelines.
• Knowledge of hospital reimbursement models and trends and their impact.
• Previous experience with and working knowledge of medical necessity screening tool.

Requirements

• Associate's of Nursing [Required]
• Bachelor's of Nursing [Preferred]
• Field Of Study N/A
• 3+ years clinical nursing [Required]
• 5+ years clinical nursing in an acute care setting [Preferred]
• Experience working in electronic health records [Preferred]
• Utilization Management or Case Management [Preferred]
• Work Schedule 4 10 hour shifts per week (weekends included)

Qualifications

• Registered Nurse (RN) [Required]
• Accredited Case Manager (ACM) [Preferred]
• OR Certified Case Manager (CCM) [Preferred]

Skills

• Strong analytical, problem-solving skills, and the ability to analyze complex data.
• Excellent interpersonal communication and 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.

Benefits

Commensurate with experience.

Pay

$32.76 - $119,520.35

Schedule

Full time Shift Day (United States of America)

Contact Information

Address: 301 MEMORIAL MEDICAL PKWY
City: DAYTONA BEACH
State: Florida
Postal Code: 32117

Company Information

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.