Adventist Health System Utilization Review RN FT Day in Ormond Beach, Florida
Florida Hospital Memorial Medical Center
Our goal at Florida Hospital Memorial Medical Center is simple: to offer our patients the absolute best care around, in the most compassionate, community-focused setting possible.
Florida Hospital Memorial Medical Center consists of two campuses: a 277-bed main hospital in Daytona Beach and a 119-bed hospital in Ormond Beach, as well as our new outpatient facility, located at the Pavilion at Port Orange. Through our Christian mission of hope, health and healing, we strive to promote wellness of mind, body and spirit. We are a recipient of the 2012 Governor’s Sterling Award, which is the highest award an organization in Florida can receive for performance excellence.
More than 400 physicians hold privileges to practice at our facilities, and we employ more than 1,700 care-team members. Our specialties include cardiology, cancer, emergency care, surgical services, obstetrics, neurosurgery, stroke care, rehabilitation, weight-loss surgery, imaging, laboratory, home health, wound care, diabetes, hospice, physician practices and women’s services.
Patients and families from across the country appreciate Florida Hospital Memorial Medical Center’s unique culture. Our cutting-edge technology is accompanied by the holistic environment and patient-centered care that have defined Florida Hospital for more than a century. Best of all, it’s just a short trip from some of Florida’s most exciting attractions—and minutes from the Sunshine State’s premier beaches
GENERAL SUMMARY :
Working in collaboration with denials RNs and under the general direction of the Director of Utilization Review, with oversight of authorization support staff workflows, this role is responsible to properly verify benefits, obtain authorizations, and perform assigned tasks within 72 hours of the admission date (ER visits) or earlier if possible. Upholds accuracy and ensures proper authorization has been secured prior to or at the time of discharge for observation and inpatient stay visits. Ensures all benefits, authorization requirements & status, and collection notes are obtained by working with commercial or managed care payers, documented clearly and thoroughly on accounts in the pursuit of timely reimbursement within certain established timeframes as determined by the Director. Maintains thorough knowledge of payer guidelines, has familiarity with payer processes for initiating authorizations, and follows through accordingly to prevent loss of reimbursement. Actively participates in team workflows & accepts responsibility in maintaining relationships that are equally respectful to all. Adheres to Florida Hospital Corporate Compliance Plan and to all rules and regulations of all applicable local, state, and federal agencies and accrediting bodies
You will be responsible for:
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.
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 ensuring 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 ensure 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 ensure 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.
Adheres to HIPAA regulations by verifying pertinent information to determine caller authorization level before releasing account information. Other duties can be assigned based upon business objectives as outlined by the Director
What will you need?
ADN, BSN or Diploma nursing degree
Active Florida Registered Nursing license
Minimum two years’ experience in case management and/or denials/appeals
Minimum five years’ acute clinical nursing experience
Basic computer skills (i.e., Word, Outlook, Excel, etc.), familiarity in Cerner EMR navigation
Working knowledge of InterQual criteria and its application.
Medical record investigative review knowledge
Proficient in using multiple computer applications interchangeably
Communicates professionally with an acceptable use of English (speaking, reading and writing)
Ability to follow oral and written directions
Ability to work independently with limited supervision
Capable of working with people of diverse backgrounds
Excellent customer service skills and great telephone etiquette
Commercial or managed care payer background preferred
ACM, CCM, CPUR, CPUM, IQCI preferred
This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances.
We are an equal opportunity employer and do not tolerate discrimination based on race, color, creed, religion, national origin, sex, marital status, age or disability/handicap with respect to recruitment, selection, placement, promotion, wages, benefits and other terms and conditions of employment.