Utilization Management RN Full Time Days in Tampa
Company: AdventHealth
Location: Orlando
Posted on: January 15, 2021
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Job Description:
Job DescriptionDescription "Utilization Management Registered
Nurse Full Time Days" AdventHealth West Florida Division Location
Address: 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 - 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 - 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. Work Hours/Shift: Full-Time Days You Will Be
Responsible For: Demonstrates through behavior AdventHealth's core
values of Integrity, Compassion, Balance,Excellence, Stewardship,
and Teamwork as outlined in the organization'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.
Qualifications 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 NursSDL2017
Keywords: AdventHealth, Orlando , Utilization Management RN Full Time Days in Tampa, Executive , Orlando, Florida
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