Utilizes effective interpersonal communication skills across department, campus and within the UM department.
Utilizes Utilization Management skills, including a thorough, working knowledge of InterQual criteria/Milliman Care Guidelines, by the following:
Review of admission, level of care and continued stay information to determine appropriateness of hospital admission status for all payers.
Communication of information to the CM (case management) team/physicians regarding patients not meeting established clinical criteria/standards/guidelines to enable and facilitate timely transfer/discharge to an alternative level of care.
Effective communication of clinical information to payers to ensure support of medical necessity/level of care to successfully avoid or reverse denials.
Complete written review/assessment of concurrent and retrospective denials; report avoidable delays based on medical records review.
Performs, at a minimum, 100 concurrent or retrospective reviews per week.
Utilizes knowledge of age specific criteria for assigned areas, utilizing UM team resources specific to adult/pediatric age groups and/or specialty populations.
What Will You Need:
EDUCATION AND EXPERIENCE REQUIRED:
Acute clinical experience of at least five (5) years
EDUCATION AND EXPERIENCE PREFERRED :
Acute clinical case management, discharge planning and/or utilization management experience in a healthcare clinical setting, i.e. hospital, managed care, home health, and/or Center for Medicare and Medicaid Services Programs, etc.
LICENSURE, CERTIFICATION, OR REGISTRATION REQUIRED:
LICENSURE, CERTIFICATION, OR REGISTRATION PREFERRED:
Certification specialty preferred in Utilization Management, Managed Care or other applicable professional certification
Actively participates in outstanding customer service and accept responsibility in maintaining relationships that are equally respectful to all. Under supervision, the UM nurse proactively coordinates case reviews for admission criteria, concurrent utilization of services, LOS (length of stay) and criteria for care, as well as retro reviews for all payers. Performs denial management activities as dictated by work flows and payer requests. Performs chart audits for all regulatory agencies as well as in-house hospital studies. Supports the campus-wide CM (case management), the physician and clinical teams in utilization activities and enhancing throughput.
This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances.
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.