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AdventHealth Utilization Management Nurse – Utilization Management – Maitland in Maitland, Florida


Utilization Management Nurse – Utilization Management – Maitland

Adventhealth 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, AdventHealth is one of the largest not-for-profit healthcare systems in the country, caring for more than a million patients each year. The 2,675-bed acute-care medical facility, comprised of nine hospitals, has been recognized by U.S. News & World Report as one of the best hospitals in the country for over 10 years. It serves as a community hospital for Greater Orlando and as a major tertiary referral hospital for Central Florida and much of the Southeast, the Caribbean and Latin America.

Work Hours/Shifts:

Mon – Fri / 8a – 5p

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 Adventhealth 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:

  • Current valid State of Florida or multi 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 AdventHealth’s Core Values of Keep Me Safe, Love Me, Make it Easy, and Own it 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 Adventhealth Maitland and apply online today.

Job Keywords:

Utilization Management Nurse, Utilization Management, Maitland

Job: Nursing

Primary Location: US-FL-Maitland

Position Location Maitland

Organization AdventHealth Central Florida

Schedule Full-time

Shift Day

Job Level Staff / Associate

Education Level Associate's Degree

Travel No

Job Posting Jun 11, 2019, 7:19:26 AM

Req ID: 281727

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.