Schedule: Full time
Shift:Day (United States of America)
Address:301 MEMORIAL MEDICAL PKWY
City:DAYTONA BEACH
State:Florida
Postal Code:32117
Job Description:- Monitor admissions and perform initial and continued stay medical necessity reviews.
- Maintain thorough knowledge of payer guidelines and regulatory requirements and manages 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 to promote interdisciplinary collaboration.
- Ensure requested clinical information is communicated, monitors daily discharge reports, and follows up with insurance carriers to obtain complete authorization.
- Other duties as assigned.
Knowledge, Skills, and Abilities:- Must be able to demonstrate knowledge and skills necessary to provide appropriate status recommendations.
- Demonstrates knowledge of the principles of growth, development, and disease states as it relates to the different life cycles.
- Ability to understand differences between notification, reference, and authorization numbers.
- Maintains up-to-date concurrent authorizations for in-house patients, utilizing daily commercial authorization reports.
- Accesses and reviews payer portals for authorization numbers in collaboration with department assistants; ensures proper update of authorization fields within EMR accordingly, delegating appropriate tasks to support staff.
- Familiarizes self with authorization requirements for assigned payers, based on payer matrix.
- Assists in assuring proper patient status authorization, by reviewing patient admission status within the electronic health record and matching with the correct authorization.
- Expedites communication with insurance contacts to assure timely authorization is received to avoid unnecessary denials.
- Demonstrates working knowledge and understanding of state and federal guidelines pertinent to care management, as well as current procedural terminology (CPT) codes and inpatient-only procedures.
- Ability to provide appropriate status recommendations based on medical necessity indicators, findings, and documentation.
- Navigates and utilizes other related software and databases to perform required actions that encompass Utilization Management.
- Demonstrates strong analytical, problem-solving skills, and the ability to analyze complex data.
- Promotes individual professional growth and development by meeting requirements for mandatory/continuing education, skills competency, supports department-based goals which contribute to the success of the organization; serves as a resource to less experienced staff.
- Excellent interpersonal communication and negotiation skill.
- Strong analytical, data management, and computer skills.
- Strong organizational and time management skills, as evidenced by capacity to prioritize multiple tasks and role components.
- Thorough knowledge of medical admission screening requirements to assist in determining appropriateness of admission, treatment requested, for a variety of conditions, per evidence-based guidelines.
- Knowledge of hospital reimbursement models and trends and their impact.
- Previous experience with and working knowledge of medical necessity screening tool.
Education:- Associate's of Nursing [Required]
- Bachelor's of Nursing [Preferred]
Schedule:Work Experience:- 3+ years clinical nursing [Required]
- 5+ years clinical nursing in an acute care setting [Preferred]
- Experience working in electronic health records [Preferred]
- Utilization Management or Case Management [Preferred]
Additional Information:Licenses and Certifications:- Registered Nurse (RN) [Required
- Basic Life Support (BLS) [Preferred]
- Accredited Case Manager (ACM) [Preferred] OR Certified Case Manager (CCM) [Preferred]
Physical Requirements: (Please click the link below to view work requirements)
- Physical Requirements - https://tinyurl.com/msy4mja2
Pay Range:$68,132.50 - $119,520.35
