The purpose of this position is to conduct initial, concurrent, retrospective chart review for clinical financial resource utilization. Coordinates with healthcare team for optimal/efficient patient outcomes, while decreasing length of stay (LOS) and avoid delays and denied days.
They are accountable for a designated patient caseload and provides intervention, coordination to decrease avoidable delays, denial of reimbursement. Specific functions within this role include: Screens pre-admission, admission process using established criteria for all points of entry.
Facilitates communication between payers, review agencies, healthcare team. Identify delays in treatment or inappropriate utilization and serves as a resource. Coordinates communication with physicians.
Identify opportunities for expedited appeals and collaborates resolve payer issues. Ensures/Maintains effective communication with Revenue Cycle Departments.
Minimum required experience 3 years. Associates degree in Nursing required.
Current Florida RN license required. Utilization Review or Case Management Certification required within 12 months of hire. 3 years of hospital clinical experience preferred. Excellent written, interpersonal communication and negotiation skills.
Strong critical thinking skills and the ability to perform clinical/chart review abstract information efficiently. Strong analytical, data management and computer skills.
Strong organizational and time management skills, as evidenced by capacity to prioritize multiple tasks and role components.
Current working knowledge of payer and managed care reimbursement preferred. Ability to work independently and exercise sound judgment in interactions with the health care team and patients/families. Knowledgeable in local, state, and federal legislation and regulations. Ability to tolerate high volume production standards.
Baptist Health South Florida