Utilization Management Clinical Supervisor -AdventHealth Trickel Building

Location Address: 900 Winderley Pl, Maitland, FL 32751

Top Reasons to work at AdventHealth Trickel Building

• Faith based & mission driven organization
• CREATION Health employee wellness and lifestyle programs
• Positive working climate to support a work life balance

Work Hours/Shift:

• Full Time

You Will Be Responsible For:   

• Supports UM staff daily and acts as a resource to the team for questions or issues that may arise.
• Accountable for day-to-day functions of assigned area, ensuring all patient accounts are verified and authorized in a timely manner with appropriate follow up for account completion.
• Supports department and team by ensuring patients receive a clinical review through system protocols accurately and timely. As needed, contacts insurance companies to address complex and challenging cases. Provides timely and continual coverage of assigned work area to ensure all accounts are completed.
• Trains all new Utilization Management employees in basic functions of the UM department and in payer-specific rules and regulations. Supervises all new UM RN’s within the 90 days’ (or extended) probationary period and completes 90-day evaluations in association with the UM Manager.
• Serves as first point of contact for initial communication with service partners and is the first stage of the escalation process to management. Accountable for maintaining a working relationship with all to ensure open communication.

EDUCATION AND EXPERIENCE REQUIRED:

• Nursing education
• Acute clinical experience of at least five (5) years

EDUCATION AND EXPERIENCE PREFERRED:

• Acute clinical case management, discharge planning and/or utilization management experience in a healthcare clinical setting, i.e. hospital, managed care, home health, and/or Center for Medicare and Medicaid Services Programs, etc.
• BSN

LICENSURE, CERTIFICATION, OR REGISTRATION REQUIRED:

• Current valid State of Florida or multi state license as a Registered Nurse

LICENSURE, CERTIFICATION, OR REGISTRATION PREFERRED:

• Certification specialty preferred in Utilization Management, Managed Care or other applicable professional certification

Actively participates in outstanding customer service and accept responsibility in maintaining relationships that are equally respectful to all.  Under supervision, the UM nurse proactively coordinates case reviews for admission criteria, concurrent utilization of services, LOS (length of stay) and criteria for care, as well as retro reviews for all payers.  Performs denial management activities as dictated by work flows and payer requests.  Performs chart audits for all regulatory agencies as well as in-house hospital studies.  Supports the campus-wide CM (case management), the physician and clinical teams in utilization activities and enhancing throughput.