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  • ID
    #5169721
  • Salary
    TBD
  • Source
    AdventHealth
  • Date
    2020-10-25
  • Deadline
    2020-12-23

Vacancy expired!

Description“Regional Manager Utilization Management RN Full Time Days”AdventHealth West Florida DivisionLocation Address:Central Business Office (Telecom Parkway, Tampa, FL)Top Reasons to Work at AdventHealthAdventHealth TampaPepin Heart Institute, known across the country for its advances in cardiovascular disease prevention, diagnosis, treatment and research.Surgical Pioneers – the first in Tampa with the latest robotics in spine surgeryBuilding a brand new, six story surgical and patient care tower which will ensure state of the art medical and surgical car for generations to comeAwarded the Get With The Guidelines – Stroke GOLD Quality Achievement Award from the American Heart Association/American Stroke Association and have been recognized as a recipient of their Target: Stroke Honor Roll for our expertise in stroke care. We have also received certification by The Joint Commission in collaboration with the American Stroke Association as a Primary Stroke Center.Work Hours/Shift:Full-Time DaysYou Will Be Responsible For:Evaluates the efficiency, clinical appropriateness, necessity of the use of medical services and procedures in the most resourceful clinical setting under the most appropriate status. Provides oversight and guidance for the day-to-day operations of the utilization review management, telephonic utilization review, prior authorization functions and support case management programs.Ensures compliance in both government and contractual guidelines and the mission, philosophy and objectives for the West Florida Region. Monitors department level compliance with HIPAA and all other Federal Regulations is followed consistently and appropriately. Supports and performs case management, disease management and all initial and concurrent review functions in collaboration with managed care/commercial payers. Maintains full knowledge of inpatient care guidelines.Maintains working knowledge of payer standards for utilization management functions for authorization requirements.Works collaboratively with physician advisors to address status change, peer-to-peer, and concurrent denial opportunities. Remains current on denial trends and performs root cause analyses to address issues.Provides ongoing education and direct clinical case reviews to support the Utilization Management team. Demonstrates clinical assessment knowledge and critical-thinking skills to support utilization review inquires, DM and denial avoidance strategies and payer and regulatory guidelines. Represents revenue cycle functions, responsibilities and acts in the best interest of the organization, reports on facility-specific findings and opportunities. Maintains caseload and performs daily pre-admission, admission and concurrent utilization reviews by leveraging Cortex logic to determine appropriate levels of care and support Care Management team for readiness for discharge. QualificationsWhat You Will Need:Current registration with Florida State Board of Nursing as a registered professional nurse or licensure from another state with verification of application and eligibility for Florida licensure by endorsement.RN, Associate or Diploma DegreeClinical experience in acute care facility – greater than three yearsPrevious experience in utilization review (minimum two years)Previous experience with denials and appeals (minimum one year)Experience with precepting/mentoring othersHospital care management experience that includes teaching and/or mentoring othersAbility to instruct educational training to varied groups of adult learners in various settingsExpertise in medical necessity screening criteria, XSOLIS/Cortex platformExpertise in Cerner Care Management systems and roles and responsibilities of various disciplinesAbility to navigate and utilize other related software and databases for educating new system end-users Demonstrates strong analytical, problem-solving skills and the ability to analyze complex dataCurrent knowledge of care management key accountabilities to engage in development and implementation of education and training of key initiativesExperience with denials and appeals for acute care hospitalsProficiency in use of spreadsheets and report softwarePREFERRED:Knowledge of payer guidelines, reimbursement methodologies, and appeals processes and their impact to AdventHealthAbility to execute Excel spreadsheets and Power Point presentationsBachelor of Science in Nursing – or other related BS or BA in addition to NursingExperience in Cerner Care ManagementACM, CCM, IQCI, CMAC, CPUR, CPUM, CRCRJob Summary:The Regional Manager of Utilization Management is a registered nurse, who works under the direction of the Regional Director of Utilization Management. The Regional Manager of Utilization Management assists the UM Director in the strategic direction setting, management, continuous improvement, and maintenance of the Utilization Management Department. This individual focuses on ensuring efficient productivity, compliant workflows, and clinically appropriate denial prevention across the region that aligns with the AdventHealth mission. This position will provide outstanding service and accepts responsibility in maintaining relationships that are equally respectful to all.This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances.We are an equal opportunity employer and do not tolerate discrimination based on race, color, creed, religion, national origin, sex, marital status, age or disability/handicap with respect to recruitment, selection, placement, promotion, wages, benefits and other terms and conditions of employment.

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