ED Utilization Management RN Remote

Hospitals, medical centers and facilities need more than physicians, nurses and specialists delivering care to our patients. A truly successful health care organization needs a thoughtful, dedicated, steady and experienced team working behind the scenes to make sure communities around the country receive the health care they need. If you’ve also been interested in working in the health care field but aren’t a health care provider, a corporate career at AdventHealth may just be the perfect fit. We’re a faith-based health care organization headquartered in Altamonte Springs, Florida. As a national leader in quality, safety and patient satisfaction, our 92,000 team members maintain a long tradition of whole-person health by caring for the physical, emotional and spiritual needs of every patient. Start your journey with a health care career at AdventHealth Corporate. 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.

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

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.