Registered Nurse Utilization Review Specialist Case Management FT Days
Florida Hospital Fish Memorial
For a young hospital built in 1994, Florida Hospital Fish Memorial has a long history dating back to 1952. Beginning as a humble, 50 bed facility more than six decades ago, we’ve grown to become one of Volusia County’s most comprehensive and trusted healthcare resources. With Florida Hospital's tremendous resources and expertise, our community hospital has continued to thrive due to constantly improving advanced medical technologies and experienced clinical talent.
Through our dedication to excellence we have been recognized as Orlando Sentinel’s "Top 100 Companies for Working Families" for 9 consecutive years. We also received the Performance Achievement Award from the Medicare Quality Improvement Organization of Florida, as well as, the 24th Annual Commissioner’s Business Recognition Award from the Florida Educational Foundation and Florida Department of Education.
As a member of Adventist Health System, Florida Hospital Fish Memorial operates as a not-for-profit organization focused on improving the health of the community it serves. This is a direct reflection of our mission to extend the healing ministry of Christ with skill and compassion." Best of all, it’s just a short trip from some of Florida’s most exciting attractions—and minutes from the beaches in Daytona!
You will be responsible for:
- The RN Clinical Case Manager/ Utilization Review Specialist will provide quality utilization case reviews and monitor hospital resource utilization processes for all patients with a primary focus on commercial, managed care insurer plans, and any Traditional Medicare denial audits. Knowledgeable and able to effectively utilize the medical necessity monitoring tool, hospital approved level of care guidelines, and or any payer specific guidelines or contractual obligations.
- Evaluates documentation on patient’s medical necessity elements and appropriateness of scheduled and direct/emergent admissions, surgeries, and other procedures/tests.
- Utilizes professional nursing knowledge to ensure that admissions and length of stay are reviewed as medically justified, and the physician’s decision-making and judgment documentation is within the patient’s medical record. Collaborates with physicians, and clinical staff to ensure resource utilization is appropriate to the patient’s clinical needs during hospitalization, and discharge planning needs, within covered payer benefits, when necessary.
- Collaborates with payer specialists, hospital discharge planners, care managers, physicians and other members of care team in order to identify, develop, and implement successful communication, education, and processes to increase staff engagement, and promote optimal clinical utilization of resources.
- Accountable for professional performance and decision-making, in accordance with the clinical, fiscal, and organizational objectives.
- Assumes responsibility for high level screening in regards to initial admission assessment and any ongoing concurrent assessment of designated patients as assigned; monitor level of care through communication with direct nursing care givers, care management team, physicians, patient and family members, and other members of the health care team.
- Reviews cases for appropriateness of admission and continued stay and appropriate discharge screening for transition plans, physician’s treatment plans and decision making; adhering to the hospital’s policies and procedures, and Case Management Department’s scope of practice and services.
- Assimilates information obtained from the emergency department visit, information system, ancillary/diagnostic tests, registration, bed management, clinics, admitting physician office, and other facilities to accurately assess patient clinical needs and treatment.
- Functions as an advocate, and contact person for the care team, patient/family when communicating with payers, and or outside agencies to assure continuity of care, optimal clinical resource outcomes, and appropriate financial management for the patient and the organization.
- Ensures initial admission reviews are completed and submitted to payer in a timely manner, same admission day or within first working day of admission; obtain certified days for patient’s presenting signs and symptoms and or documented primary diagnosis with treatment plan with the confirmation of level of care and admission status (patient type) appropriateness throughout the patient’s hospital stay.
- Investigates with resolution of unauthorized clinical days and payment denials by payer for clinical services, same working day; front-end denial prevention prior to patient discharge.
What will you need?
- BS in Nursing or ASN.
- Current Florida RN license
- Graduate of an accredited School of Nursing
- Minimum 3 years’ Registered Nurse experience in an acute care hospital required.
- Registered Nurses hired into the case management department with limited experience in Hospital Case Management Program may participate in orientation, education programs, preceptorship and validation of performance for up to a total of three to six months, to include validation of 30/60/90-day (s) employment evaluation.
- Two (2) years’ experience in utilization review, resource management, care coordination and transitional planning; hospital denials and appeals; experience in managed care, commercial payer guidelines and business care management services preferred
- Case Management Certification / Accreditation preferred