Utilization Review RN 1, Intl Healthcare Partnerships, Per Diem, 08:30A-5P

Baptist Health South Florida • Coral Gables, FL

12h • Onsite

About The Position

This position conducts concurrent retrospective reviews for clinical, financial, and resource utilization. It coordinates with the Healthcare team to achieve optimal efficient outcomes, decreasing length of stay (LOS) and avoiding delays/denied days. The role helps drive change by identifying areas of performance improvement (e.g., day to day workflow, education, process improvements, patient satisfaction). The Utilization Review RN is accountable for a designated caseload and provides intervention and coordination to decrease avoidable delays/denial of payment resources. Specific functions include: Facilitation of pre-certification and payer authorization processes, screening of the pre-admission and admission process by using established criteria for all points of entry, facilitating communication between payers, review agencies, and the healthcare team. The role identifies delays in treatment or appropriate utilization and serves as a resource, applying process improvement methodologies in evaluating outcomes of care. It involves coordinating communication with physicians, identifying opportunities for expedited appeals, and collaborating to resolve payer issues. The Utilization Review RN ensures and maintains effective communication with Revenue Cycle Departments, Access Management, and other members of the healthcare team to ensure timely communication to payers.

Requirements

• RN license
• MCG Specialist Certification-SCG/GCR
• One of the listed certifications required
• 3 years of Nursing experience preferred
• 2 years of hospital or payor utilization management experience required
• Excellent written, interpersonal communication and negotiation skills.
• Strong critical thinking skills and the ability to perform clinical chart review abstract information efficiently.
• Strong analytical, data management and computer skills.
• Strong organizational and time management skills, as evidenced by capacity to prioritize multiple tasks and role components.
• Ability to work independently and exercise sound judgment in interactions with the health care team and patients/families.
• Knowledgeable in local, state, and federal legislation and regulations.
• Ability to tolerate high volume production standards.
• Minimum Required Experience: 3 Years

Nice To Haves

• Current working knowledge of payer and managed care reimbursement preferred.
• RNs hired prior to 2-2012 (10/1/2017 at Bethesda or 7/1/2019 at BRRH) with an Associates Degree in Nursing are not required to have a BSN to continue their non-leadership role as an RN. however, they are required to complete the BSN within 3 years of job entry date.

Responsibilities

• Conducts concurrent retrospective reviews for clinical, financial, resource utilization.
• Coordinates with Healthcare team to achieve optimal efficient outcomes, decreasing length of stay (LOS) and avoiding delays/denied days.
• Helps drive change by identifying areas of performance improvement (e.g., day to day workflow, education, process improvements, patient satisfaction).
• Is accountable for a designated caseload and provides intervention, coordination to decrease avoidable delays/denial of payment resources.
• Facilitates pre-certification and payer authorization processes.
• Screens pre-admission and admission process by using established criteria for all points of entry.
• Facilitates communication between payers, review agencies and health care team.
• Identifies delays in treatment or appropriate utilization and serves as a resource.
• Applies process improvement methodologies in evaluating outcomes of care.
• Coordinates communication with physicians and identifies opportunities for expedited appeals.
• Collaborates to resolve payer issues.
• Ensures/Maintains effective communication with Revenue Cycle Departments Access Management and other members of the healthcare team to ensure timely communication to payers.

Benefits

• Career growth and development opportunities, with clear pathways and ongoing support
• Comprehensive health and wellness resources that go beyond traditional benefits
• A wellness program that can help employees eliminate their medical plan deductible, reducing out-of-pocket healthcare costs
• Tuition reimbursement to support continued learning and advancement

What This Job Offers

• Job Type: Part-time
• Career Level: Mid Level
• Number of Employees: 5,001-10,000 employees