Utilization Management Specialist PRN

Adventist Health System Daytona Beach , FL 32114

Posted 2 months ago

Job 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


What you will need:


  • 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 of Care Management processes / workflows


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


  • 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.

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Utilization Management Specialist PRN

Adventist Health System