The Utilization Management Educator serves the AdventHealth Utilization Management (UM) and Denial Prevention (DP) department. Develops, assesses, plans, implements, and evaluates procedures and processes for the system, provides continuing education, assesses for and implements process improvement, and change management. The UM/DP Educator is actively involved in future planning and strategic development for system UM and DP needs, to include but not limited to; policy development, program development, ongoing audits for the region and quality improvement efforts. Works under general supervision and utilizes critical thinking skills. The UM/DP Educator adheres to the AdventHealth Corporate Compliance Plan and to all rules and regulations of all applicable local, state, and federal agencies and accrediting bodies. Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all. Is agile in recognizing the needs of the individual departments and responds to these needs in a timely manner.
PRINCIPAL DUTIES AND JOB RESPONSIBILITIES:
Â· Demonstrates, through behavior, AdventHealthâ™s core values of Integrity, Compassion, Balance, Excellence, Stewardship, and Teamwork.
Â· Develops, produces, and delivers training for UM and Denial Prevention on an ongoing basis. This includes new hire training, annual training, and on an as needed basis for current employees in the UM and Denial Prevention Departments.
Â· Audits new UM/Denial Prevention RNs during their 90-day probationary period. Presents written and verbal updates to the UM/Denial Prevention RNs and their Managers and Directors. Provides additional education based on results of audits and provides input for the 90-day evaluation.
Â· Assists UM/DP Managers in completing monthly quality audits for all UM/DP RNs. Identifies additional education opportunities for individuals and the departments based on audit findings.
Â· Completes monthly audits for the Corporate scorecard.
Â· Maintains UM/Denial Prevention department SharePoint by reviewing and updating content on a regular basis. This includes, but is not limited to, UM flows, regulatory information, and required forms.
Â· Reviews and revises UM Policies and SOPs annually, or as needed.
Â· Identifies external education opportunities for UM/Denial Prevention staff including webinars and continuing education.
Â· Acts as the SME (Subject Matter Expert) for Utilization Management/Denial Prevention for Revenue Cycle related projects.
Â· Acts as a liaison between CM leadership, staff members of the Revenue Cycle, clinical leadership, other interdisciplinary team members at all applicable levels of leadership, and external partners. Communicates appropriately and effectively with all involved parties.
Â· Submits quarterly education plan to the director and adjusts as needed based on direction of the leader.
Â· Reviews data with the data analysts to look for ROI of education efforts and adjusts educational plan as required based on the data analysis.
Â· Keeps abreast of all regulatory changes that will affect the strategic processes of UM/DP and plans education around these changes as needed, including consistent follow-up with the teamâ™s compliance.
Â· Will be considered a key liaison to any DNV, ACHA, or other regulatory visits that directly affect these departments.
KNOWLEDGE AND SKILLS REQUIRED:
Â· Experience in Utilization Management or Denial Management
Â· Past healthcare education experience
Â· Excellent communication techniques in oral and written form
Â· Computer knowledge including basic computer skills in Windows and Outlook
Â· Excellent ability in making presentations to management, staff, and business partners
Â· Comfortable in a complex and changing healthcare environment
Â· Medical record investigative review knowledge
Â· Ability to multi-task and work in a potentially stressful, fast-paced environment with tight timelines
Â· Ability to be self-directed when required, and work independently with limited supervision
Â· Excellent customer service skills and communication etiquette
KNOWLEDGE AND SKILLS PREFERRED:
Â· Knowledge of specific AdventHealth computer-based programs
Â· Excel proficiency
EDUCATION AND EXPERIENCE REQUIRED:
Â· Graduate of school of Nursing
Â· Bachelorâ™s degree in a field such as nursing, management, business
Â· Minimum of three (3) yearsâ™ experience as an RN in an acute clinical setting.
EDUCATION AND EXPERIENCE PREFERRED:
Â· Masterâ™s degree in Nursing Education, or related health care related field
Â· Experience in education in a healthcare or Care Management or Utilization Management setting
LICENSURE, CERTIFICATION OR REGISTRATION REQUIRED:
Â· State of Florida current valid RN nursing license.
LICENSURE, CERTIFICATION OR REGISTRATION PREFERRED:
Â· Certification specialty preferred in Utilization Management, managed care or other applicable professional certification.
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.