Ed Utilization Management Rn Night Remote

AdventHealth Corporate

All the benefits and perks you need for you and your family:

    Benefits from Day One

    Career Development

    Whole Person Wellbeing Resources

    Mental Health Resources and Support

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.

Shift: opening for 3pm-3am shift and openings for 7pm-7am shift

Job Location: Remote

The role you'll contribute:

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 acce

The value that you bring to the team:

1)   Performs pre-admission status recommendation in Emergency Department or elective procedure settings as assigned, to communicate with providers status guidance based on available information.

2)            Leverages clinical experience and critical thinking to provide status assignment recommendations to providers within an abbreviated timeframe.  

3)       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.

4)            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.

5)            Utilizes advanced conflict resolution skills as necessary to ensure timely resolution of issues.

6)            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

7)  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.

8)  Completes patient history indicators in Cortex platform, based on available information, to optimize accuracy of Care Level Scores

9)  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.

10) Performs additional tasks (e.g., continued stay reviews, discharge reconciliation) as assigned by leadership.

11)     Demonstrates the understanding of requirements for pre-certification process by payers; familiar with ICD-10 and DRG coding principles.

12)     Working knowledge of Inpatient/Outpatient Medicare procedures, commercial or managed care special contracted payer inpatient -vs-outpatient procedures.

13)     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.

The expertise and experiences you'll need to succeed:

       RN, Associate or Bachelor of Science Nursing

       Current and valid license to practice 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 qualifications:

       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

       RN licensure at bachelor's level (or related bachelor's degree in addition to RN licensure).

       ACM/CCM certification preferred.