RN Utilization Manager

RN Utilization Management Nurse – Frontline Opportunity

Greater Orlando, Florida

The RN Utilization Management Nurse uses clinical expertise by analyzing patient records to determine legitimacy of hospital admission, treatment, and appropriate level of care. The Utilization Management RN leverages the algorithmic logic of the platform, utilizing key clinical data points to assist in status and level of care recommendations. The UM RN is responsible for documenting findings based on department and regulatory standards.

When screening criteria does not align with the physician order or a status conflict is indicated, the Utilization Management Nurse is responsible for escalation to the Physician Advisor or designated leader for additional review as determined by department standards. Additionally, the RN Utilization Management Nurse is responsible for denial avoidance strategies including concurrent payer communications to resolve status disputes.

• Registered Nurse
• ADN or BSN required
• 3 years Acute Care Clinical Nursing experience required
• 2 years Utilization Management experience
• Excellent interpersonal communication and negotiation skills
• Strong analytical, data management, and computer skills
• Strong organizational and time management skills, as evidenced by capacity to prioritize multiple tasks and role components

• Bachelor of Science in Nursing – or other related BS or BA in addition to Nursing
• Clinical experience in acute care facility – greater than five years
• 4 years Utilization Management within Acute Care Hospital setting

• Monitors admissions and performs initial patient reviews within 24 hours of admission; and when warranted by length of stay, utilization review plan, and/or best practice guidelines, on a continuing basis
• Performs pre-admission status recommendation in Emergency Department or elective procedure settings as assigned, to communicate with providers status guidance based on available information
• Maintains thorough knowledge of payer guidelines, familiarity with payer processes for initiating authorizations, and following through accordingly to prevent loss of reimbursement, including the management of concurrent and pre-bill denials
• Ensuring all benefits, authorization requirements, and collection notes are obtained and clearly documented on accounts in the pursuit of timely reimbursement within established time frames to avoid denials
• Works collaboratively and maintains active communication with physicians, nursing and other members of the multi-disciplinary care team to effect timely, appropriate management of claims
• Utilizes advanced conflict resolution skills as necessary to ensure timely resolution of issues
• Collaborates with the physician and all members of the multidisciplinary team to facilitate care for designated case load; monitoring the patient's progress, intervening as necessary and appropriate to ensure that the plan of care and services provided are patient focused, high quality, efficient, and cost effective; facilitating the following on a timely basis Communication to third party payors and other relevant information to the care team
• Assignment of appropriate levels of care
• Ability to work independently and exercise sound judgment in interactions with physicians, payors, patients and their families
• Completion of all required documentation in the Cortex platform and in the system's electronic health record
• Escalating otherwise unresolved status conflicts appropriately and timely to the physician advisor to avoid concurrent denials
• Collaborates with medical staff, nursing staff, payor, and ancillary staff to eliminate barriers to efficient delivery of care in the appropriate setting
• 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
• Actively participates in clinical performance improvement activities
• Assists in the collection and reporting of resource and financial indicators including LOS, cost…