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All the benefits and perks you need for you and your family:

Benefits from Day One

Career Development

Whole Person Wellbeing Resources

Mental Health Resources and Support

Our promise to you:

Joining AdventHealth is about being part of something bigger. Its about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit. AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding that **together** we are even better.

**Shift** : Monday- Friday Full Time 8am-5pm

**Job Location** : Remote

The role you will contribute:

The Utilization Management nurse uses clinical expertise to review for medical necessity and recommend an appropriate level of care. It involves documenting findings based on department and regulatory standards, and escalating cases when necessary to optimize patient classification and payer notifications. This position utilizes denial avoidance strategies, including concurrent payer communications to resolve status disputes..

The value you will bring to the team:

Monitor admissions and perform initial and continued stay medical necessity reviews.

Maintain thorough knowledge of payer guidelines and regulatory requirements and manages concurrent and pre-bill denials to prevent loss of reimbursement.

Collaborate and communicate with the multidisciplinary care team regarding patient status and concurrent denials.

Build relationships to promote interdisciplinary collaboration.

Ensure requested clinical information is communicated, monitors daily discharge reports, and follows up with insurance carriers to obtain complete authorization.

Other duties as assigned.

The expertise and experiences you'll need to succeed:

Associate's of Nursing Degree

3 years clinical nursing experience

Registered Nurse (RN)

Must be able to demonstrate knowledge and skills necessary to provide appropriate status recommendations. Must demonstrate knowledge of the principles of growth, development, and disease states as it relates to the different life cycles.

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. Assists in assuring proper patient status authorization, by reviewing patient admission status within the electronic health record and matching with the correct authorization. Expedites communication with insurance contacts to assure timely authorization is received to avoid unnecessary denials.

Demonstrates working knowledge and understanding of state and federal guidelines pertinent to care management, as well as current procedural terminology (CPT) codes and inpatient-only procedures.

Must be able to demonstrate knowledge and skills necessary to provide appropriate status recommendations based on medical necessity indicators, findings, and documentation.

Ability to navigate and utilize other related software and databases to perform required actions that encompass Utilization Management.

Demonstrates strong analytical, problem solves skills and the ability to analyze complex data

Promotes individual professional growth and development by meeting requirements for mandatory/continuing education, skills competency, supports department-based goals which contribute to the success of the organization; serves as a resource to less experienced staff.

Excellent interpersonal communication and negotiation skill

Strong analytical, data management, and computer skills.

Strong organizational and time management skills, as evidenced by capacity to prioritize multiple tasks and role components.

Thorough knowledge of medical admission screening requirements to assist in determining appropriateness of admission, treatment requested, for a variety of conditions, per evidence-based guidelines.

Knowledge of hospital reimbursement models and trends and their impact to AdventHealth.

Previous experience with and working knowledge of medical necessity screening tool.

Strong analytical and problem solves skills.

Preferred Qualifications:

Bachelor's of Nursing

5 years clinical nursing in an acute care setting

Experience working in electronic health records

Accredited Case Manager (ACM) OR

Certified Case Manager (CCM)

This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances. The salary range reflects the anticipated base pay range for this position. Individual compensation is determined based on skills, experience and other relevant factors within this pay range. The minimums and maximums for each position may vary based on geographical location.

**Category:** Case Management

**Organization:** AdventHealth Corporate

**Schedule:** Full-time

**Shift:** 1 - Day

**Req ID:** 25042045

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.