Utilization Management Nurse - Utilization Management - Maitland

Florida Hospital

Posted 2 months ago

Listing Type: Nursing
Employment Type: Nursing
Shift: Days
Education Level: BSN Required
Certificates: Not Stated
Experience Level: All|Experienced
Compensation: NA

Complete Job Description

Utilization Management Nurse – Utilization Management – Maitland

Florida Hospital Maitland seeks to hire a Utilization Management Nurse who will embrace our mission to extend the healing ministry of Christ.

Facility Profile:

Established in 1908, Florida Hospital is one of the largest not-for-profit healthcare systems in the country, caring for more than a million patients each year. The Maitland Office Plaza houses our highly skilled teams that support our hospital system including Marketing, Patient Financial Services, Revenue Management, the Credit Union and Human Resources. The Trickel Building, a two-story office structure, creates an atmosphere of health and healing, with a healthy-style café and quaint chapel. The main lobby is filled with lush greenery and a light trickle of water, creating a holistic environment.

Work Hours/Shifts:

Days and hours are flexible

Job Summary:

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.

Knowledge, Skills, Education, & Experience Required:

Working knowledge of clinical care criteria and its application.
Medical record investigative review knowledge.
Computer knowledge including basic computer skills; Windows and Outlook
Knowledge of specific Florida Hospital computer-based programs as well as Microsoft word, Excel and Outlook (Preferred)
Nursing education
Acute clinical experience of at least five (5) years
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. (Preferred)
BSN (Preferred)

Licensure, Certification, or Registration Required:

Clear/Active Florida State license as a Registered Nurse
Certification specialty preferred in Utilization Management, Managed Care or other applicable professional certification (Preferred)

Job Responsibilities:

Demonstrates through behavior Florida Hospital’s Core Values of Integrity, Compassion, Balance, Excellence, Stewardship and Teamwork as outlined in the organization’s Performance Excellence Program

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.
Performs other duties as assigned or directed by the UM Director or Manager to ensure the smooth operation of the department
Certain UM RN’s may be asked to be part of payer specific teams, such as Medicaid or Medicare Audit reviewers as required by work flows/volumes.

If you want to be a part of a team that is dedicated to delivering the highest quality in patient care, we invite you to explore the Utilization Management Nurse opportunity with Florida Hospital Maitland and apply online today.

Job Keywords:

Utilization Management, Nurse, Maitland
Utilization Management Nurse – Utilization Management – Maitland — 272171

Locations(s) : Florida Hospital – Maitland
Schedule : Full-time
Shift : Day

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