Job Description

Overview

Halifax Health is seeking a Utilization Review (UR) Case Manager for the Discharge Planning/Case Management Department.

Summary

The primary responsibility of the Utilization Review Case Manager is to review medical records, document medical necessity and prepare concurrent clinical appeals (when appropriate) on medical necessity, level of care, length of stay, and authorization denials for hospitalized patients. An understanding of the severity of an array of illnesses, intensity of service, and care coordination needs are key, as the nurse must integrate clinical knowledge with billing knowledge to review, evaluate, and appeal clinical denials related to the care provided to the hospitalized patient. The utilization review nurse works with the multidisciplinary team to assess and improve the denial management, documentation, and appeals process of such findings. The utilization review nurse manages all activities related to the monitoring, interpreting, and appealing of concurrent clinical denials received from third-party payers and ensures accuracy in patient billing. The position is integral to the organization, as successful appeals by the nurse result in preventing denied claims and preserving revenue. Those in the position also work in collaboration with physician advisers to support policy development, process improvement, and staff education related to clinical denial mitigation.

Job Qualifications

Completion of an accredited LPN or RN nursing program

Three years acute care experience in a hospital setting

One year as a utilization review nurse preferred

Strong computer skills required

Licensed Nurse in the State of Florida

Demonstrates effective interpersonal and communication skills

Demonstrates flexibility via an ability to adapt to changing priorities

Demonstrates good customer relations

Ability to prioritize assignments and effective time-management skills

Basic knowledge of clinical and psychosocial aspects of patient care

Must be detail oriented, flexible, and committed to patient advocacy

Demonstrates skills in planning, organizing, and managing multiple functions and complex processes

Excellent verbal and written communication skills required

Knowledge of basic computer software programs

Knowledge of area community resources and referrals

Job Duties and Responsibilities

Performs and documents initial certification and continued stay reviews in appropriate time frame and appropriate database

Obtains information from patient, caregivers, providers of services, insurance company, benefits administrators and others as necessary

Conveys complete and accurate clinical information to payor throughout certification process

Researches benefit data and options, programs and other forms of assistance that may be available to the client, and negotiates for services as indicated

Communicates pertinent reimbursement information to healthcare team while observing patient right to confidentiality

Verifies in-network verses out-of-network benefits and communicates date to the patient and healthcare team as indicated

Maintains follow-up communication with payor as required; confirms certification date with payor at time of discharge

Documents obtained financial information in a complete, timely and concise manner

Notifies Utilization Review Supervisor, Case Management Director, Medical Director of Utilization Management and/or CMO as appropriate, of all unresolved utilization problems or issues

Identifies trends in care, processes or services that may provide opportunities for improvement in a patient population, provider population or service unit

Takes initiative to participate in a quality/process improvement initiative

Identifies quality and risk management issues; refer issues for corrective action as appropriate

Collaborates with the interdisciplinary team to create solutions and take corrective actions to address issues resulting in variances in the plan of care

Evaluates research studies and applies findings to improve case management and service delivery

Remains at all times a firm patient advocate; seeks to obtain and maintain quality care for all clients regardless of payor type

Observes at all times legal and ethical considerations pertaining to client confidentiality

Assumes accountability for facilitating patient\xe2\x80\x99s plan of care throughout their hospital stay

Contributes to an overall team effort and actively participates in multidisciplinary rounds by communicating information regarding patients meeting medical necessity and level of care

Serves as a resource for other members of the healthcare team by participates in or conducts formal/informal in-service education as indicated

About Us

Recognized as one of the 50 Top Cardiovascular Hospitals\xe2\x84\xa2 in the United States by IBM Watson Health\xe2\x84\xa2, Halifax Health serves Volusia and Flagler counties, providing a continuum of health care services through a network of organizations including a tertiary hospital, two community hospitals, urgent care clinics, psychiatric services, a cancer treatment center with five outreach locations, the area\xe2\x80\x99s largest hospice, a center for inpatient rehabilitation, outpatient rehabilitation clinics, primary care walk-in clinics, a clinic specializing in women\xe2\x80\x99s health, a pediatric care community clinic, five pediatric medical practices, a home health care agency and an exclusive provider organization. Halifax Health offers the area\xe2\x80\x99s only Level II Trauma Center, Thrombectomy-Capable Stroke Center (TSC), Center for Transplant Services, Pediatric Intensive Care Unit, Child and Adolescent Behavioral Services, complete Neurosurgical Services, OB Emergency Department and Level III Neonatal Intensive Care Unit that cares for babies born earlier than 28 weeks. For more information, visit halifaxhealth.org.

Halifax Health