âœUtilization Management Registered Nurse Full Time Daysâ AdventHealth West Florida Division
Location Address: Central Business Office (Telecom Parkway, Tampa, FL)
Top Reasons to Work at AdventHealth
AdventHealth Tampa Pepin Heart Institute, known across the country for its advances in cardiovascular disease prevention, diagnosis, treatment and research.
Surgical Pioneers â“ the first in Tampa with the latest robotics in spine surgery
Building a brand new, six story surgical and patient care tower which will ensure state of the art medical and surgical car for generations to come
Awarded the Get With The Guidelines â“ Stroke GOLD Quality Achievement Award from the American Heart Association/American Stroke Association and have been recognized as a recipient of their Target: Stroke Honor Roll for our expertise in stroke care. We have also received certification by The Joint Commission in collaboration with the American Stroke Association as a Primary Stroke Center.
You Will Be Responsible For:
Demonstrates through behavior AdventHealthâ™s core values of Integrity, Compassion, Balance, Excellence, Stewardship, and Teamwork as outlined in the organizationâ™s Performance Excellence Program.
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.
Applies approved clinical appropriateness criteria to monitor appropriateness of admissions and continued stays, and documents findings based on Department standards.
Demonstrates ability to understand differences between notification, reference, and authorization numbers. Maintains up-to-date concurrent authorizations for in-house patients, utilizing daily commercial authorization reports. 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. Assist in assuring proper patient status authorization, by reviewing patient admission status within the Cerner Care Manager system and matching with the correct authorization. Expedites communication with insurance contacts to assure timely authorization is received.
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. 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), level of acuity, and appropriate plan of care.
Works proactively to avoid inpatient denials, providing additional information and clarification to commercial contacts as appropriate, facilitating peer-to-peer reviews and/or concurrent appeals process when necessary in close collaboration with facility Case Mgmt. Obtains information from the insurance carrier regarding their concurrent/retrospective appeal process in the event of claim denial.
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.
Provides timely and continual coverage of assigned work area in order to ensure all accounts are completed. Meets attendance requirements, and is flexible during periods of short staffing, and/or high volume.
Actively participates in clinical improvement activities by assisting in the collection and reporting of resources and financial indicators including LOS, cost per case, avoidable days, resource utilization, readmission rates, denials, and appeals.
Adheres to HIPAA regulations by verifying pertinent information to determine caller authorization level before releasing account information.
Ensures safe care by adhering to policies, procedures and standards, within budgetary specifications, including time management, supply management, productivity and accuracy of practice. Oher duties can be assigned based upon business objectives as outlined by the Director.
What You Will Need:
ADN, BSN, or Diploma nursing degree
Minimum two (2) years experience in case management and/or denials/appeals
Minimum five (5) years acute clinical nursing experience
Active Florida Registered Nursing license
Working knowledge of InterQual criteria and its application.
Medical record investigative review knowledge.
Basic computer skills (ie. Word, Outlook, Excel, etc.), familiarity in Cerner EMR navigation
Commercial or managed care payer background (Preferred)
ACM, CCM, CPUR, CPUM, IQCI (Preferred)
Proficient in using multiple computer applications interchangeably
Communicates professionally with an acceptable use of English (speaking, reading, and writing)
Ability to follow oral and written directions
Ability to work independently with limited supervision
Capable of working with people of diverse backgrounds
Excellent customer service skills and great telephone etiquette
Working in collaboration with denials RNs and under the general direction of the Director of Utilization Review, with oversight of authorization support staff workflows, this role is responsible to properly verify benefits, obtain authorizations, and perform assigned tasks within 72 hours of the admission date (ER visits) or earlier if possible. Upholds accuracy and ensures proper authorization has been secured prior to or at the time of discharge for observation and inpatient stay visits. Ensures all benefits, authorization requirements & status, and collection notes are obtained by working with commercial or managed care payers, documented clearly and thoroughly on accounts in the pursuit of timely reimbursement within certain established timeframes as determined by the Director. Maintains thorough knowledge of payer guidelines, has familiarity with payer processes for initiating authorizations, and follows through accordingly to prevent loss of reimbursement. Actively participates in team workflows & accepts responsibility in maintaining relationships that are equally respectful to all. Adheres to Florida Hospital Corporate Compliance Plan and to all rules and regulations of all applicable local, state, and federal agencies and accrediting bodies.
AdventHealth Greater Orlando (formerly Florida Hospital) is one of the largest faith-based health care providers in the United States. For 150 years, we have carried on a tradition of providing whole-person care that not only addresses patients' physical ailments, but also supports their emotional and spiritual well-being. We demonstrate the same level of compassion and care for our employees as well, doing all that we can to help them realize their full potential – both personally and professionally.