AdventHealth Utilization Review Registered Nurse in Daytona Beach, Florida
Registered Nurse Utilization Review AdventHealth Daytona Beach
Location Address: 301 Memorial Medical Parkway Daytona Beach, FL 32117
Top Reasons to Work at AdventHealth Daytona Beach
Great benefits such as: Educational Reimbursement
Career growth and advancement potential
High quality of life with low cost of living on the shores of sunny Daytona Beach, FL.
Full Time / Day
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.
What You Will 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
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.
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.