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Form of work
SalaryAdventHealth 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 : Full-time; Monday-Friday
Job Location : Remote
The role you’ll contribute:
The Divisional Manager of Utilization Management (UM) is a registered nurse, who works under the direction of the Divisional Director of Utilization Management, and provides oversight for the strategic direction setting, management, continuous improvement, and maintenance Utilization Management team. The Divisional Manager assists the UM Director in the strategic planning and daily operations of the team members dedicated to obtaining timely authorizations, avoiding unnecessary denials, and ensuring productivity standards are maintained throughout the department. This individual focuses on ensuring efficient productivity, compliant workflows, and clinically appropriate denial prevention across the region that aligns with the AdventHealth mission. This position will provide outstanding service standards and accepts responsibility in maintaining relationships that are equally respectful to all.
The value that you bring to the team:
- Evaluates the efficiency, clinical appropriateness, necessity of the use of medical services and procedures in the most resourceful clinical setting under the most appropriate status
- Ensures staffing needs are adequate to support authorization functions, ongoing claim authorizations, Utilization Management requirements, telephonic Utilization Management, denial avoidance and intervention activities, and to maintain collaborative workflows with Care Management
- Collaborates with facility level Care Management staff as needed to address and resolve Utilization Management related concerns/issues
- Ensures compliance with both government and contractual guidelines
- Ensures staff compliance with regulatory requirements including but not limited to: Condition Code 44, two-midnight inpatient certification audits, physician orders for correct status level, etc.
- Supports staff in daily pre-admission, admission, concurrent, and/or retrospective utilization reviews (as assigned) by leveraging Cortex logic to determine/support appropriate levels of care
- Maintains working knowledge of payor standards for Utilization Management functions for authorization requirements
- Collaborates with managed care partners and commercial payors to quickly address authorization or medical necessity concerns
- Works collaboratively with Physician Advisors to address status change recommendations, peer-to-peer reviews, and concurrent denial opportunities
- Participates in hospital/medical staff meetings to review patients meeting medical necessity related to high dollar cases seeks assistance from Utilization Management Divisional Director, as needed
- Remains current on denial trends and performs root cause analyses to address issues
- Provides ongoing education and direct clinical case reviews to support the Utilization Management team, as well as facility specific goals to improve Utilization Management, denial avoidance, and compliance with payors and Centers for Medicare & Medicaid Services (CMS)
- Assists in the development and oversees the implementation of Utilization Management policies, procedures, and standards
- Escalates provider related concerns to Physician Advisor(s) and ensures resolution
- Reports pertinent quality/risk issues to appropriate individuals, departments and/or committees in a timely manner
- Strives to meet all key performance indicator (KPI) targets
- Performs chart reviews to validate that policy, procedure and standards are met
- Plans, organizes and delegates activities as required for safe, efficient and effective operations of the unit/area including active participation with other facility and leadership staff
- Encourages team member engagement
- Holds regular staff meetings and encourages staff to share information and participate in decision making
- Maintains excellent professional relationships with facility and divisional leadership
- Communicates and collaborates across the Utilization Management team in the areas of data and information management, performance improvement, obtaining timely authorizations, avoiding unnecessary denials, prior authorization functions, ongoing claim authorizations, and Utilization Management requirements
- Meets productivity standards and staffing needs
- Fosters a work environment favorable to retaining staff
- Responsible for personnel functions including staffing, performance reviews and corrective action
- Promotes professional growth and development of employees
- Maintains a predictable schedule, including time on and off shifts such as weekends and holidays
- Maintains collegial relationships with staff, physicians, and other departments
- Maintains open communication with staff
- Hires and retains individuals with appropriate skills and works to develop staff to their highest potential
- Assures adherence to applicable policies, procedures, and guidelines
- Consults with Utilization Management Divisional Director and Human Resources for performance issues as appropriate
- Fosters professionalism, independence and critical thinking
- Demonstrates a positive problem-solving attitude to staff, physicians and peers
- Supports financial responsibility of Utilization Management and viability of department resources
- Assists in development of an action plan to address variances (positive and negative)
- Supports flexible scheduling to meet the needs of staff members, and achieve productivity while remaining within budget
- Formulates contingency plans for staffing during times of low census
The expertise and experiences you’ll need to succeed:
- RN, Associate or Diploma Degree
- Clinical experience in acute care facility – greater than three years
- Previous experience in utilization review (minimum two years)
- Previous experience with denials and appeals (minimum one year)
- Experience with precepting/mentoring others (minimum two years)
Preferred Qualifications:
- Bachelor of Science in Nursing – or other related BS or BA in addition to Nursing
- RN licensure at bachelor’s level (or related bachelor’s degree in addition to RN licensure)
- Knowledge of payer guidelines, reimbursement methodologies, and appeals processes and their impact to AdventHealth
- Ability to execute Excel spreadsheets and Power Point presentations
This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances. The salary range reflects the anticipated base pay range for this position. Individual compensation is determined based on skills, experience and other relevant factors within this pay range. The minimums and maximums for each position may vary based on geographical location.
Category: Case Management
Organization: AdventHealth Corporate
Schedule: Full-time
Shift: 1 - Day
Req ID: 24010984
We are an equal opportunity employer and do not tolerate discrimination based on race, color, creed, religion, national origin, sex, marital status, age or disability/handicap with respect to recruitment, selection, placement, promotion, wages, benefits and other terms and conditions of employment.
