RN - Utilization Review and Management - Experience a Must!

Orlando Health•Orlando, FL

46d•Hybrid

About The Position

This role promotes and facilitates effective management of hospital resources from admission to discharge. The RN collaborates with the assigned clinical team to identify patients who would benefit from care coordination services. This includes assessing patients’ risk factors, the need for care coordination, clinical utilization management, and the transition to the next appropriate level of care. The position is initially for 3 months in an office setting, then transitions to remote/hybrid. A minimum of 3-5 years of experience in a hospital setting doing utilization management is required.

Requirements

Graduate of an approved school of nursing.
Must hold and maintain a current Florida RN license.
Three (3) years of experience in chronic disease management, care management, care coordination, utilization management, or acute clinical care.
Must have 3-5 years in a hospital setting doing utilization management.

Nice To Haves

Handle with Care (HWC) Certification is required for the Behavioral Health Unit within 90 days of hire. The Handle with Care training and education will be provided onsite to all team members.

Responsibilities

Initially and concurrently assesses all patients within assigned population to include: 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.
Communicates appropriately and timely with the interdisciplinary team and third-party payers.
Prioritizes activities in assigned areas to focus on high risk, high cost, and problem prone areas.
Develops collaborative relationships with patient business, nursing, physicians, and patient/family to facilitate efficient movement through the continuum of care.
Monitors and evaluates data, fiscal outcomes, and other relevant information to develop and implement strategies for improvement.
Forwards identified quality and/or risk issues appropriately.
Maintains positive relationships with outside/onsite reviewers and other payer representatives.
Identifies cultural, socio-economic, religious, and other factors that may impact treatment.
Involves patient’s family in the development of the treatment plan as appropriate while explaining procedures, therapies, systems treatment plans, and discharge plans in age/developmental/educational specific terms to patient/family.
Reviews patient’s discharge plan at multidisciplinary meetings and/or staffing to facilitate communication with other healthcare team members.
Prioritizes workload to manage multiple priorities while using problem-solving skills to meet goals.
Enhances professional growth by participating in educational programs, current literature and/or workshops.
Possesses excellent interpersonal skills and ability to work in a team environment.
Respects the rights and privacy of others and holds staff member information in strict confidence.
Maintains reasonably regular, punctual attendance consistent with Orlando Health policies, the ADA, FMLA and other federal, state and local standards.
Maintains compliance with all Orlando Health policies and procedure.