Utilization Management RN Remote

AdventHealth•Orlando, FL

2d•Remote

About The Position

The Utilization Management RN monitors admissions and performs initial and continued-stay medical necessity reviews. The role maintains knowledge of payer guidelines and regulatory requirements and manages concurrent and pre-bill denials to help prevent reimbursement loss. The RN collaborates and communicates with the multidisciplinary care team regarding patient status and concurrent denials, builds relationships that support interdisciplinary collaboration, communicates requested clinical information, monitors daily discharge reports, and follows up with insurance carriers to obtain complete authorization. The RN provides appropriate status recommendations, maintains current concurrent authorizations for in-house patients using daily commercial authorization reports, reviews payer portals for authorization numbers in collaboration with department assistants, and ensures authorization fields in the electronic medical record are updated appropriately. The role may delegate appropriate tasks to support staff. This is a full-time remote position with a weekend-focused schedule: four 10-hour days, either 6:30 a.m.–5:00 p.m. or 7:00 a.m.–5:30 p.m. The templated schedule includes five out of six weekends in each six-week rotation.

Requirements

Associate's degree in Nursing.
At least 3 years of clinical nursing experience.
Registered Nurse (RN) license.
Knowledge and skills necessary to provide appropriate status recommendations.
Knowledge of principles of growth, development, and disease states as they relate to different life cycles.
Ability to distinguish notification, reference, and authorization numbers.
Ability to maintain current concurrent authorizations and update authorization fields in the electronic medical record.
Full-time schedule of four 10-hour days, including five out of six weekends per six-week rotation.

Nice To Haves

Bachelor's degree in Nursing.
At least 5 years of clinical nursing experience in an acute care setting.
Experience working with electronic health records.
Utilization Management or Case Management experience.
Accredited Case Manager (ACM) certification.
Certified Case Manager (CCM) certification.

Responsibilities

Monitor admissions and perform initial and continued-stay medical necessity reviews.
Maintain knowledge of payer guidelines and regulatory requirements.
Manage concurrent and pre-bill denials to prevent loss of reimbursement.
Collaborate and communicate with the multidisciplinary care team regarding patient status and concurrent denials.
Build relationships that promote interdisciplinary collaboration.
Ensure requested clinical information is communicated.
Monitor daily discharge reports and follow up with insurance carriers to obtain complete authorization.
Provide appropriate status recommendations.
Maintain up-to-date concurrent authorizations for in-house patients using daily commercial authorization reports.
Access and review payer portals for authorization numbers in collaboration with department assistants.
Ensure authorization fields are properly updated in the electronic medical record and delegate appropriate tasks to support staff.