Utilization Management Specialist PRN

Adventist Health System Daytona Beach , FL 32114

Posted 2 months ago

Job Description:

Description

Utilization Management Specialist/Assistant PRN Days

AdventHealth Daytona Beach

Location Address: 301 Memorial Medical Parkway Daytona Beach, FL 32117

Top Reasons to Work at AdventHealth Daytona Beach

Immediate Health Insurance Coverage

High End Technology in the Lab

Great benefits such as: Educational Reimbursement

Career growth and advancement potential

High quality of life with low cost of living on the shores of sunny Daytona Beach, FL.

Work Hours/Shift:

PRN / Day

What you will be responsible for:

  • Coordinates and supports clerical and administrative activities of the Utilization Management team

  • Collaborates and communicates with payor via phone, fax or payor portal

  • Submits clinical reviews to payors

  • Provides information to payors supporting admission /continued stay

  • Manages requests submitted from payors

  • Provides discharge dates to payors

  • Submits copies of UM activities to payors, as needed

  • Tracks and monitors requests through EMR

  • Ensures incoming requests are responded to promptly and accurately

  • Obtains and enters authorization numbers from payors

  • Verifies up-to-date concurrent authorizations for in-house patients

  • Reviews and monitors accounts to ensure proper documentation of benefits and authorizations have been completed in required fields and notes

  • Supports concurrent denials process

  • Assists in coordinating Peer-to-Peer discussions with the payor for Physician Advisors, Attending Physicians and UM RNs

  • Updates patient demographic/patient type/coverage, as needed

  • Assists UM Coordinator in managing central fax (Vyne)/email accounts (Central Repository), as needed

  • Communicates with all members of the Interdisciplinary Team (i.e., nurses, physicians, etc.), as needed

  • Assists department leadership with quality audits as needed

  • Timely escalates cases requiring clinical expertise to UM RNs

  • Interacts with physicians, physician office personnel, and/or care management departments on an to assure resolution of issues, as needed

  • Provides timely and continual coverage of assigned work area in order to ensure all accounts are completes

  • Monitors daily discharge reports to assure all patient stay days are authorized

  • Maintains a working knowledge of payor contracts and regulatory requirements

  • Adheres to the policies, procedures, rules, regulations, and laws of the hospital and federal and state regulatory bodies

  • Communicates and collaborates with Patient Financial Services (PFS) and Health Information Management (HIM) to render appropriate information needed to secure reimbursement, as needed

  • Collaborates with Care Management team to ensure payor compliance regulations (i.e. Condition Code 44)

  • Adheres to HIPAA regulations by verifying pertinent information to determine caller authorization level before releasing account information.

  • Completes any other tasks within department guidelines

Qualifications

What you will need:

KNOWLEDGE AND SKILLS REQUIRED:

  • Understanding of Microsoft Office Products and other appropriate software platforms

  • Knowledge of Utilization Management

  • Ability to communicate effectively and professionally via phone and email

  • Ability to manage multiple tasks and prioritize level of importance

  • Ability to perform duties in a manner to promote quality patient care and customer service/satisfaction, while promoting safety and a commitment to AH principles

  • Ability to work with people of all social, economic, and cultural backgrounds; be flexible, open-minded and adaptable to change

  • Ability to work with minimal supervision

KNOWLEDGE AND SKILLS PREFERRED:

  • Knowledge of Care Management processes / workflows

EDUCATION AND EXPERIENCE REQUIRED:

  • High School diploma or GED
  • Two (2) years' experience in Patient Access, Revenue Cycle Operations, Pre-Access, or related department

EDUCATION AND EXPERIENCE PREFERRED:

  • Associate degree and/or higher-level education, or completed coursework, in Health Services Administration or other related medical or business field

Job Summary:

The Utilization Management (UM) Specialist works under the direction of the Utilization Management Manager and supports the Utilization Management team with Emergency, Observation and Inpatient visits. The UM Specialist is responsible for providing clerical assistance to the Utilization Management Nurses (UM RN) to assist with verification of benefits, authorization procurement and other assigned tasks as needed. The UM Specialist is responsible for collaborating with the UM RN and other members of the interdisciplinary team (i.e. Physicians, Care Managers, Social Workers, etc.) or interdependent departments (i.e. Patient Access, Billing, etc.) to ensure unnecessary delays in patient care, discharge or billing.

The UM Specialist will serve as the first point of escalation for payors requiring assistance in gaining additional or missing information to support authorization. The UM Specialist will be responsible for ensuring procurement of authorization upon admission and discharge as well as, accuracy of authorization information. The UM Specialist will ensure timely escalation of barriers to authorization requiring clinical expertise and assist in coordination of Peer to Peer discussions with the payor.

This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances.

icon no score

See how you match
to the job

Find your dream job anywhere
with the LiveCareer app.
Mobile App Icon
Download the
LiveCareer app and find
your dream job anywhere
App Store Icon Google Play Icon
lc_ad

Boost your job search productivity with our
free Chrome Extension!

lc_apply_tool GET EXTENSION

Similar Jobs

Want to see jobs matched to your resume? Upload One Now! Remove
Utilization Management RN Supervisor Full Time Days

Adventist Health System

Posted 2 weeks ago

VIEW JOBS 11/10/2021 12:00:00 AM 2022-02-08T00:00 Job Description Description Utilization Management RN Supervisor Full Time Days AdventHealth Daytona Beach Location Address: 301 Memorial Medical Parkway Daytona Beach, FL 32117 100% REMOTE POSITION Top Reasons to Work at AdventHealth * Great benefits such as: Educational Reimbursement * Career growth and advancement potential * High quality of life with low cost of living * Immediate Benefits Work Hours/Shift: Full-Time / Days You Will Be Responsible For: * Supervises daily operations as directed by Divisional Utilization Management Manager, including: o Daily supervision of Utilization Management staff o Primary point of contact for Utilization Management barriers or concerns o May manage own assignment and department outcomes, as directed * Assists Utilization Management Manager to successfully implement practice changes * Serves as an initial point of contact for all identified stakeholders [i.e. Utilization Management staff, Physician Advisor(s), payors, leadership] * Serves as a Utilization Management content expert regarding medical necessity criteria, patient status, level of care, regulatory compliance, etc. * Performs chart reviews to validate that policy, procedure and standards are met * Escalates operational and/or financial concerns to the Physician Advisor(s), as appropriate * Reports pertinent quality/risk issues to appropriate individuals, departments and/or committees in a timely manner * Discusses staff, physician, and other department complaints with Utilization Management Manager and follows up with a written report submitted within 24 hours, as needed * Maintains caseload and performs daily pre-admission, admission, and concurrent utilization reviews by leveraging Cortex logic to determine appropriate levels of care and support Care Management team for readiness for discharge, as directed * Demonstrates a positive problem-solving attitude to staff, physicians and peers * Serves as a supportive change agent for Utilization Management model processes * Acts as a role model for Utilization Management department staff * Encourages team member engagement * Maintains open communication with staff * Assists with staff performance reviews/evaluations * Provides support and oversight with progressive corrective action plans * Balances schedules to meet department needs prior to posting * Communicates changes to expected schedule; minimizes unscheduled absences * Plans job responsibilities for maximum utilization of staff * Resolves daily staffing issues * Knowledge of Care Management processes/workflows * Knowledge of Utilization Management processes, medical necessity criteria, and compliance guidelines * Ability to lead others effectively * Ability to manage multiple tasks and prioritize level of importance * Critical thinking skills * Customer service skills * Ability to implement process improvement processes * Experience with Microsoft applications and development of reports * Strong professional verbal and electronic communication * Ability to negotiate optimal resolution of issues * Ability to engage in complex clinical decision making * Conflict resolution skills * Ability to analyze, evaluate, and monitor data * Ability to foster positive Interdisciplinary Team relations and encourage employee engagement * Ability to work independently and/or as part of a team Qualifications What You Will Need: * RN License (required) * Associate Degree in Nursing * Minimum three years acute care clinical nursing experience required. * 2-3 years of experience in direct Utilization Management with increasing level of responsibility * 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 * Bachelor of Science in Nursing * Clinical experience in acute care facility * Experience mentoring others * ACM, CCM (preferred) Job Summary: The Utilization Management RN Supervisor reports directly to the Divisional Utilization Management RN Manager and assists in monitoring and performing the daily operations and supervision of team members in the Utilization Management department. Utilization Management team members will have defined reporting accountabilities directly to Supervisors. The Utilization Management RN Supervisor is responsible for the daily administrative tasks as assigned by the Utilization Management RN Manager. The Supervisor will serve as the primary point of contact for Utilization Management staff, physicians, and payors to provide mitigation for any barriers/concerns that may arise. The Utilization Management RN Supervisor will be responsible for supporting positive and safe patient outcomes, employee evaluations, and customer experience. This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances. Adventist Health System Daytona Beach FL

Utilization Management Specialist PRN

Adventist Health System