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AdventHealth Registered Nurse CM UR Specialist in Orange City, Florida


Registered Nurse Care Manager Utilization Review Specialist AdventHealth New Smyrna Beach

Location Address: 401 Palmetto Street, New Smyrna, Florida 32168

Top Reasons to Work at AdventHealth New Smyrna 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 New Smyrna Beach.

Work Hours/Shift:

Full Time / Day

You Will Be Responsible For:

  • Assumes responsibility for high level screening in regards to initial admission assessment and any ongoing concurrent assessment of designated patients as assigned; monitor level of care through communication with direct nursing care givers, care management team, physicians, patient and family members, and other members of the health care team.

  • Reviews cases for appropriateness of admission and continued stay and appropriate discharge screening for transition plans, physician’s treatment plans and decision making; adhering to the hospital’s policies and procedures, and Case Management Department’s scope of practice and services.

  • Assimilates information obtained from the emergency department visit, information system, ancillary/diagnostic tests, registration, bed management, clinics, admitting physician office, and other facilities to accurately assess patient clinical needs and treatment.

  • Functions as an advocate, and contact person for the care team, patient/family when communicating with payers, and or outside agencies to assure continuity of care, optimal clinical resource outcomes, and appropriate financial management for the patient and the organization.

  • Ensures initial admission reviews are completed and submitted to payer in a timely manner, same admission day or within first working day of admission; obtain certified days for patient’s presenting signs and symptoms and or documented primary diagnosis with treatment plan with the confirmation of level of care and admission status (patient type) appropriateness throughout the patient’s hospital stay.

  • Investigates with resolution of unauthorized clinical days and payment denials by payer for clinical services, same working day; front-end denial prevention prior to patient discharge.

  • Assumes responsibility for the completion of the Florida Medicaid process for patient admission, continued stay, discharge and or post-acute services approval.

  • Works collaboratively with physicians to improve the overall quality of clinical documentation reflects the patient’s presenting severity of illness for hospitalization, and to establish accurate assignment of patient status orders (observation, inpatient), concurrently, throughout the patient’s hospital stay.

  • Maintains ongoing communication with medical staff, caregivers, care management team, and third party payers to set priorities, plan, organize and implement care goals directed

  • Toward best practice quality outcomes, timely and efficiently.

  • Participates in the Case Management Department’s implementation and monitoring of utilization management regulatory requirements.


What You Will Need:

  • BS in Nursing or ASN

  • Current FL RN License

  • Graduate of an accredited School of Nursing

  • Minimum 3 years’ Registered Nurse experience in an acute care hospital required.

  • Registered Nurses hired into the case management department with limited experience in Hospital Case Management Program may participate in orientation, education programs, preceptorship and validation of performance for up to a total of three to six months, to include validation of 30/60/90 day (s) employment evaluation.

  • Two (2) years’ experience in utilization review, resource management, care coordination and transitional planning; hospital denials and appeals; experience in managed care, commercial payer guidelines and business care management services and Case Management Certification / Accreditation preferred

Job Summary:

The RN Clinical Case Manager/ Utilization Review Specialist demonstrates professional nursing knowledge and hospital care management services with the ability to perform the necessary primary role(s) of a cross-trained skill-set hospital case manager in listed area (s) of expertise, following hospital and case management policies and processes, to include, but not limited to:

  • Access Management/Utilization Review - Preadmission evaluation or screening

  • Hospital Outpatient Services

  • Hospital Care Management Services – Acute Care

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.