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 multi-disciplinary 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;
Assignment of appropriate levels of care;
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;
Escalating otherwise unresolved status conflicts appropriately and timely to the physician advisor to avoid concurrent denials.
Collaborates with medical staff, nursing staff, payor, and ancillary staff to eliminate barriers to efficient delivery of care in the appropriate setting. Communicates with all parties (i.e., staff, physicians, payers, etc.) in a helpful and courteous manner while extending exemplary professionalism. Anticipates and responds to inquiries and needs in an assertive, yet courteous manner. Demonstrates positive interdepartmental communication and cooperation.
Actively participates in clinical performance improvement activities.
Assists in the collection and reporting of resource and financial indicators including LOS, cost per case, avoidable days, resource utilization, readmission rates, concurrent denials, and appeals.
Uses data to drive decisions and plan/implement performance improvement strategies related to care management for assigned patients, including fiscal, clinical, and patient satisfaction data.
Collects, analyzes, and addresses variances from the plan of care/care path with physician and/or other members of the healthcare team. Uses concurrent variance data to drive practice changes and positively impact outcomes.
Collects delay and other data for specific performance and/or outcome indicators as determined by Director of Care Management.
Documents key clinical path variances and outcomes which relate to areas of direct responsibility (e.g., discharge planning). Uses pathway data in collaboration with other disciplines to ensure effective patient management concurrently.
Ensures requested clinical information has been communicated as requested. Monitors daily discharge reports to assure all patient stay days are authorized. Follows up with insurance carrier to obtain complete authorization to avoid concurrent or retrospective denials. Communicates with the other departments / team members for resolutions of conflicts between status and authorization. Evaluates clinical review(s) and physician documentation for at-risk claims; performs additional reviews and/or include pertinent addendums to fortify/reinforce basis for accurate claim reimbursement. Demonstrates a strong understanding of medical necessity (i.e., severity of illness, intensity of service, risk), level of acuity, and appropriate plan of care.
Interacts with physicians, physician office personnel, and/or case management departments on an as-needed basis to assure resolution of pending denials, which have been referred to the physician for peer-to-peer review with the Medical Director of the insurance carrier.
KNOWLEDGE AND SKILLS REQUIRED:
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.
KNOWLEDGE AND SKILLS PREFERRED:
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.
What You Will Need:
RN license (required)
Current and valid license to practice as a Registered Nurse (ADN or BSN) required. (required)
Minimum three years acute care clinical nursing experience required.
Minimum two years Utilization Management experience, or equivalent professional experience. (required)
Excellent interpersonal communication and negotiation skill. (required)
Strong analytical, data management, and computer skills. (required)
Strong organizational and time management skills, as evidenced by capacity to prioritize multiple tasks and role components. (required)
Bachelor of Science in Nursing – or other related BS or BA in addition to Nursing (preferred)
Clinical experience in acute care facility – greater than five years. (preferred)
Minimum four years Utilization Management within acute care setting. (preferred)
Experience working in electronic health records of at least two years. (preferred)
RN licensure at bachelor’s level (or related bachelor’s degree in addition to RN licensure). (preferred)
ACM/CCM certification preferred.
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 Utilization Management Nurse is accountable for a designated patient caseload and responsible for specific functions within the role including:
Facilitating precertification and payor authorization processes as required, ensuring proper authorization has been secured prior to or at the time of discharge for observation and inpatient stay visits to avoid unnecessary denials.
Working in collaboration with facility Care Management to ensure that high quality health care services are provided in a cost-efficient and compliant manner, in line with regulatory standards.
Adhering to all rules and regulations of applicable local, state, and federal agencies and accrediting bodies.
Actively participating in team workflows and accepting responsibility in maintaining relationships
At AdventHealth, Extending the Healing Ministry of Christ is our mission. It calls us to be His hands and feet in helping people feel whole. Our story is one of hope — one that strives to heal and restore the body, mind and spirit. Our more than 80,000 skilled and compassionate caregivers in hospitals, physician practices, outpatient clinics, urgent care centers, skilled nursing facilities, home health agencies and hospice centers are committed to providing individualized, wholistic care.