Registered Nurse - Utilization Review Experience a Must - Full Time

Orlando Health•Orlando, FL

About The Position

Must have previous utilization management experience. A care manager is vital to the patient as well as the hospital and ongoing expenses to be paid for care. You must understand complex documentation and have strong written and verbal communication skills.

Requirements

Graduate of an approved school of nursing.
Must hold and maintain a current Florida RN license.
Handle with Care (HWC) Certification is required for the Behavioral Health Unit within 90 days of hire.
Three (3) years of experience care management, care coordination and utilization management

Responsibilities

Promotes and facilitates effective management of hospital resources from admission to discharge, collaborating with the assigned clinical team to identify patients most likely to benefit from care coordination services to include assessing patients’ risk factors and the need for care coordination, clinical utilization management and the transition to the next appropriate level of care.
Initially and concurrently assesses all patients within assigned population to include, but not limited to:
Accurate medical necessity screening and submission for Physician Advisor review
Care coordination that includes admitting diagnosis/ medical history, current treatments, age, payment source, resources, support systems, anticipated needs, expected length of stay, appropriate level of service, special/ personal needs, and other relevant information.
Assignment of initial DRG to determine GMLOS, while concurrently monitoring and managing LOS and transition planning as appropriate through assessment and reassessment and the application of InterQual guidelines.
Leading and facilitating multi-disciplinary patient care conferences
Managing concurrent disputes
Making appropriate referrals to other departments
Identifying and referring complex patients to Social Work Services
Communicating with patients and families about the plan of care
Leading and facilitating Complex Case Review
Identification and documentation of potentially avoidable days
Identification and reporting over and underutilization
Ensures compliance with all regulatory standards including Federal, State, Local and Joint Commission with review requirements for Managed Contracts, Medicare, Medicaid, and Campus related to admission and continued stay approval.
Adheres to Utilization Management Plan.
Integrates National standards for care management scope of services including:
Utilization Management supporting medical necessity and denial prevention
Transition Management promoting appropriate length of stay, readmission prevention and patient satisfaction
Care Coordination by demonstrating throughput efficiency while assuring care is the right sequence and appropriate level of care
Education provided to physicians, patients, families, and caregivers