Utilization Management Registered Nurse - Remote

The role of the Utilization Management (UM) Registered Nurse (RN) is to use clinical expertise by analyzing patient records to determine legitimacy of hospital admission, treatment, and appropriate level of care. The UM RN leverages the algorithmic logic of the XSOLIS Cortex platform, utilizing key clinical data points to assist in status and level of care recommendations. The UM RN is responsible to document findings based on department and regulatory standards. When screening criteria does not align with the physician order or a status conflict is indicated, the UM nurse is responsible for escalation to the Physician Advisor or designated leader for additional review as determined by department standards. Additionally, the UM RN is responsible for denial avoidance strategies including concurrent payer communications to resolve status disputes.

The value you'll bring to the team: 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. Maintaining 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 timeframes to avoid denials. Works collaboratively and maintains active communication with physicians, nursing and other members of the multidisciplinary 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; monitors 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; facilitates the following on a timely basis: Communication to third party payors and other relevant information to the care team; 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. Qualifications The expertise and experiences you'll need to succeed: EDUCATION AND EXPERIENCE REQUIRED: Current and valid license to practice in Florida as a Registered Nurse (ADN or BSN) required. Minimum three years acute care clinical nursing experience required. Minimum two years Utilization Management experience, or equivalent professional experience. 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. PREFERRED: 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 Minimum four years Utilization Management within acute care setting Experience working in electronic health records of at least two years REGISTRATION REQUIRED: Registered Nurse

• 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.
• Maintaining 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 timeframes to avoid denials.
• Works collaboratively and maintains active communication with physicians, nursing and other members of the multidisciplinary 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; monitors 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; facilitates the following on a timely basis: Communication to third party payors and other relevant information to the care team;
• 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.

• Current and valid license to practice in Florida as a Registered Nurse (ADN or BSN) required.
• Minimum three years acute care clinical nursing experience required.
• Minimum two years Utilization Management experience, or equivalent professional experience.
• 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.

• Benefits from Day One
• Paid Days Off from Day One
• Debt-free Education*

At AdventHealth Orlando, what started as a converted farmhouse in rural Central Florida has become Central Florida’s major tertiary health care facility. Patients come from the Southeast, the Caribbean and even as far as South America for our proven expertise and compassionate health care. With a variety of Orlando hospital jobs, we invite you to start or elevate your career with a new job at AdventHealth Orlando. We constantly seek out Orlando nurses, medical assistants, nurse assistants, patient care and health administration professionals who share our passion for whole-person health care. Learn more about our open positions and apply to become an invaluable part of our team. Every day, our fellow team members show up to work, unified by one shared mission: Extending the Healing Ministry of Jesus Christ. As a faith-based health care organization, our story is one of hope as we strive to heal and restore the body, mind and spirit. Though our facilities are spread across the country, this unwavering belief binds us together. Across every office, exam and patient room, we're committed to providing individualized, holistic care. This is our Christian mission, and it inspires us to help make communities healthier and happier. All the benefits and perks you need for you and your family: · Benefits from Day One · Paid Days Off from Day One · Debt-free Education* (Certifications and Degrees without out-of-pocket tuition expense) Schedule: Full Time Remote, Applicant must live within a 50-mile radius or be a current employee within an AdventHealth region. Shift : Monday – Friday, 8am - 4:30pm, every 4 th weekend, may vary based on business needs. The community you'll be caring for: The Maitland Office Plaza houses our highly skilled teams that support our hospital system including Marketing, Patient Financial Services, Revenue Management, the Credit Union and Human Resources. The Trickle Building, a two-story office structure, creates an atmosphere of health and healing, with a healthy-style café and quaint chapel. The main lobby is filled with lush greenery and a light trickle of water, creating a holistic environment. Our promise to you: Joining AdventHealth is about being part of something bigger. It’s 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.