San Antonio, Texas
La Plata, Maryland
Posted: 05-Feb-25
Location: Orlando, Florida
Categories:
Internal Number: 25003914
All the benefits and perks you need for you and your family:
- Benefits from Day One
- Paid Days Off from Day One
- Career Development
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; Mon-Fri, 8a-430p. Weekend rotation.
Shift: Days
The role you’ll contribute: 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 points to assist in status and level of care recommendations. The UM RN is responsible to document findings based on department and regulatory standards. When screening criteria does not align with the physician order or a status conflict is indicated, the UM nurse is responsible for escalation to the Physician Advisor or designated leader for additional review as determined by department standards. Additionally, the UM RN is responsible for denial avoidance strategies including concurrent payer communications to resolve status disputes. The Utilization Management Nurse is accountable for a designated patient caseload and responsible for specific functions within the role including: •Facilitating precertification and payor authorization processes as required, ensuring proper authorization has been secured prior to or at the time of discharge for observation and inpatient stay visits to avoid unnecessary denials. •Working in collaboration with facility Care Management to ensure that high quality health care services are provided in a cost-efficient and compliant manner, in line with regulatory standards. •Adhering to all rules and regulations of applicable local, state, and federal agencies and accrediting bodies. •Actively participating in team workflows and accepting responsibility in maintaining relationships.
The value you’ll bring to the team:
- 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[1]disciplinary care team to effect timely, appropriate management of claims.
- Utilizes advanced conflict resolution skills as necessary to ensure timely resolution of issue
The expertise and experiences you’ll need to succeed:
Minimum qualifications:
- 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 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.
