Utilization Management RN

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.

Monitor admissions and perform initial and continued stay medical necessity reviews. 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. Other duties as assigned.

Must be able to demonstrate knowledge and skills necessary to provide appropriate status recommendations. Demonstrates knowledge of the principles of growth, development, and disease states as it relates to the different life cycles. 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. Assists in assuring proper patient status authorization, by reviewing patient admission status within the electronic health record and matching with the correct authorization. Expedites communication with insurance contacts to assure timely authorization is received to avoid unnecessary denials. Demonstrates working knowledge and understanding of state and federal guidelines pertinent to care management, as well as current procedural terminology (CPT) codes and inpatient-only procedures. Ability to provide 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.