Utilization Review Specialist – Center for Behavioral Health – Orlando — 244336

Florida Hospital

Posted 1 week ago

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

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Utilization Review Specialist – Center for Behavioral Health – Orlando — 244336

Job Category: Professional – Non-Clinical
Location: Orlando, FL

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Florida Hospital Orlando seeks to hire a Utilization Review Specialist in the Center for Behavioral Health who will embrace our mission to extend the healing ministry of Christ.

Florida Hospital Orlando Facility Profile

Located on a lush tropical campus, our flagship hospital, 1,107-bed Florida Hospital Orlando, serves as the major tertiary facility for much of the Southeast, the Caribbean and South America. Florida Hospital Orlando houses one of the largest Emergency Departments and largest cardiac catheterization labs in the country. We are already one of the busiest hospitals in the nation, providing service excellence to more than 32,000 inpatients and 125,000 outpatients each year.

Work Hours/Shifts

Times vary

Majority of time will be Monday – Friday

However, some weekend and evenings may be needed depending on Hospital need

Job Summary

Independently manages and performs clinical authorizations and reviews for patients admitted to Florida Hospital, through continuous coordination with clinical staff, psychiatric utilization care managers and payer mix. The Utilization Review Specialist provides comprehensive knowledge and leadership in utilization review, works collaboratively with the Admissions Supervisor and leads optimizing financial outcomes. Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all.
Knowledge Skills, Education & Experience Required:
Effective written and presentation communication skills. Ability to communicate regularly with up-line and other designated contacts within the organization.
Advanced knowledge in Microsoft Word, Excel and PowerPoint.
Ability to work effectively independently and in a team-based environment.
Strong proficiency in multi-tasking and organizational skills.
Comprehensive benefits knowledge with payer mix.
Scheduling flexibility in ability to work days, evenings and weekends.
Ability to perform critical in-depth analysis of medical records for appropriateness and level of care.
Ability to provide exceptional customer service.
Strong problem-solving and analytical skills.
Ability to maintain confidentiality in all aspects of the job.
Ability to make business decisions that are financially responsible, accountable, justifiable and secure in accordance with organization policies and procedures.
Three years of experience specializing in psychiatric utilization review
Experience in complex problem solving

Licensure, Certification, or Registration Required

Current valid State of Florida license as a Licensed Clinical Social Worker or Licensed Mental Health Counselor

Job Responsibilities

Demonstrates, through behavior, Florida Hospital’s core values of Integrity, Compassion, Balance, Excellence, Stewardship and Teamwork.
Utilizes comprehensive knowledge of patient benefits with payer mix to optimize treatment interventions to provide daily relevant expertise to the Clinical Interdisciplinary Team comprised of psychiatrists, physicians, nurses, social workers and other disciplines.
Oversees daily workflow and work assignment of the Utilization Review case manager(s) which includes but is not limited to daily assignment of work, preparation of census report identifying patient payer status, length of stay (LOS), coverage days approved by payer, last covered day (LCD), exhausted benefits, uninsured/self-pay patients and denials. This process includes notification to stakeholders on the Interdisciplinary Clinical Team, CBH Administration and Admissions team.
Completes thorough and timely concurrent daily reviews for admissions and continued stays according to specified criteria by the Utilization Review and Care Management departments; participates in coordination and facilitation of second-level reviews.
Maintains current knowledge of payer mix and regulatory requirements, updates the Interdisciplinary Clinical Team, CBH Operations Manager, the Admissions Supervisor and Admissions lead(s).
Prepares and maintains ongoing statistical data to monitor utilization and case review of all patients according to payer source, LOS, uninsured/self-pay, LCD, denials and exhausted benefits.
Maintains professional relationship with clinical staff to ensure continuity of care and assist with discharge planning, coordination of care for inpatient patients and aftercare in-home health services
Facilitates quarterly staff education regarding psychiatric utilization management process and effective clinical documentation, and develops quality indicators for evaluation of service efficacy
Maintains monthly, or more frequently when needed, meetings/conference calls in collaboration with FH/AHS Managed Care to enhance financial outcomes and provide payer mix feedback. Attends 20% of meetings on behalf of CBH Operations Manager specific to payer mix, Managed Care initiatives, and quality improvement ideas by participation in appropriate hospital committees.
Performs additional duties as assigned or directed to ensure the smooth operation of the department.

The above statements reflect the general duties and responsibilities necessary to describe the principal functions of the job, as identified, and shall not be considered an exhaustive list of job responsibilities which may be inherent in the job. Responsibilities are subject to change.

Keywords: utilization specialist

Call to Action

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 Review Specialist opportunity with Florida Hospital Orlando and apply online today.