AdventHealth Careers for Veterans

Job Information

AdventHealth Utilization Review Registered Nurse Full Time Days in Ocala, Florida


Utilization Review Registered Nurse Full Time Days" AdventHealth Ocala

Location Address: 1500 SW 1 st Ave Ocala, Florida 34471

Top Reasons To Work At AdventHealth Ocala

  • Horse Capital of the World

  • Driving distance to Gainesville, St. Augustine, Orlando, Tampa, Sarasota

  • Part of the community since 1898, providing healthcare to Marion County for over 120 years

  • Florida Hospital Ocala offers a broad spectrum of services, with programs that are nationally recognized and accredited

  • Spectacular springs throughout the county

Work Hours/Shift:

Full Time Days

You Will Be Responsible For:

  • Responsible for performing utilization reviews on Medicare, Medicaid, Commercial insurances, HMOs, and third party payors.

  • Communicates with physicians regarding utilization review and compliance issues.

  • Maintains current knowledge of resources available within the community, maintains supply of resource materials to be distributed to patients when needed. Is able to obtain other resources as needed.

  • Communicates as needed with admissions personnel regarding admissions and discharges to various units.

  • Involved in performance improvement activities in the department as assigned.

  • Cooperates with insurance company requests and provides relevant information to support severity of illness, intensity of service, and admission status.

  • Collaborates with the Managed Care Coordinator, Denials Coordinator, and other individuals involved in the billing process to assure appropriate UR is performed and that documentation is the record is accurate and appropriate.

  • Actively participates in Denials meetings, ANSB/CCT conference calls and other meetings related to UR practices and as deemed necessary by department director.

  • Identifies improvement opportunities related to Utilization Review and shares these with the other department members to help facilitate overall improvement.

  • Demonstrates an ability to be flexible, organized, and function under stressful situations.

  • Maintains a good working relationship both within the department and with other departments.

  • Consults other departments as appropriate to collaborate on utilization review and performance improvement activities.

  • Documentation meets current standards and policies.

  • Continually maintains and respects confidentiality of patient/physician/personnel information

  • Is effective in optimizing payment reimbursement through ongoing process of accurate and appropriate utilization review practices.

  • Performs other duties and functions as directed and assigned by Department Director.

  • Consistently displays World Class behaviors every day in every situation


What You Will Need:

  • Registered Nurse with active Florida license

  • Associate degree in Nursing

  • One year of acute care nursing

  • Knowledge of clinical nursing process

  • Patient information computer experience


  • Experience as a hospital Case Manager preferred

  • Interqual knowledge and ability to apply accurately and appropriately

  • Has working knowledge of billing requirements for Medicare, Medicaid, HMOs, and private insurance companies.

  • Is knowledgeable of compliance standards for Medicare and Medicaid

  • Experience with Cerner Patient Information system preferred

  • ACM or CCM preferred

  • Rehab, Restorative, Palliative, Hospice certified a plus

Job Summary:

Performs utilization review functions including those related to Medicare, Medicaid, HMO and Commercial insurance Assures ongoing compliance with billing standards and practices. Provides education to the Case Management staff regarding denials and opportunities for improvement related to UR practices. Works in collaboration with other departments to assure accurate and appropriate documentation to support correct admission status.

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.