“ED Utilization Management RN Full Time Nights” AdventHealth West Florida Division
Location Address: Central Business Office (Telecom Parkway, Tampa, FL)
You Will Be Responsible For:
Performs pre-admission status recommendation in Emergency Department or elective procedure settings as assigned, to communicate with providers status guidance based on available information.
Leverages clinical experience and critical thinking to provide status assignment recommendations to providers within an abbreviated timeframe.
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.
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:
Assignment of appropriate patient status and level of care;
Ability to work independently and exercise sound judgment in interactions with any physicians and/or other interdisciplinary team members;
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 as outlined in department workflow
Communicates with all parties (i.e., staff, physicians, etc.) in a timely, 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.
Completes patient history indicators in Cortex platform, based on available information, to optimize accuracy of Care Level Scores
Actively participates in clinical performance improvement activities.
Uses data to drive decisions and plan/implement performance improvement strategies 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.
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.
Performs additional tasks (e.g., continued stay reviews, discharge reconciliation) as assigned by leadership.
Demonstrates the understanding of requirements for pre-certification process by payers; familiar with ICD-10 and DRG coding principles.
Working knowledge of Inpatient/Outpatient Medicare procedures, commercial or managed care special contracted payer inpatient –vs-outpatient procedures.
Maintains knowledge and or skill set related to patient’s presenting illness, or, severity of illness and intensity of services necessary for treatment and recovery
What You Will Need:
RN, Associate or Bachelor of Science Nursing
Current and valid license to practice as a Registered Nurse (ADN or BSN) required.
Strong analytical, data management, and computer skills.
Strong organizational and time management skills, as evidenced by capacity to prioritize multiple tasks and role components.
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.
Familiarizes self with authorization requirements for assigned payers, based on payer matrix.
Demonstrates working knowledge and understanding of state and federal guidelines pertinent to utilization 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.
EDUCATION AND EXPERIENCE 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
LICENSURE, CERTIFICATION OR REGISTRATION PREFERRED:
RN licensure at bachelor’s level (or related bachelor’s degree in addition to RN licensure).
ACM/CCM certification preferred.
The role of the Emergency Department 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. This coverage will be required twenty-four hours per day, seven days a week including weekends, holidays and overnight.
The Emergency Department 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 Emergency Department 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.
The Utilization Management Nurse is accountable for a designated patient caseload and responsible for specific functions within the role including:
Reviewing available patient records pre-admission, providing timely status recommendations to optimize correct patient classification and corresponding payer notifications/authorizations
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.