Registered Nurse Care Manager Utlization Review in Tavares, FL at AdventHealth

Date Posted: 6/6/2019

Job Snapshot

  • Job Schedule
  • Location:
    Tavares, FL
  • Job Category
  • Date Posted:
  • Job ID:
  • Job Family
    Case Management
  • Travel
  • Shift
    1 - Day
  • Application Zone
    1-Shared Services
  • Organization
    AdventHealth Waterman

Job Description


Registered Nurse Care Manager Utilization Review AdventHealth Waterman

Location Address: 1000 Waterman Way Tavares, Florida 32778

Top Reasons to Work at AdventHealth Waterman

Immediate Health Insurance Coverage

Sign on Bonus

Great benefits such as: Onsite daycare, educational reimbursement

Career growth and advancement potential

High quality of life with low cost of living just outside of Orlando, Florida

Work Hours/Shift:

Full Time/ Day

You Will Be Responsible For:


  • Performs timely and compliant admission, status, and continued stay reviews, appropriately applying InterQual criteria and 2midnight rule guidelines.

  • Assigns working DRG in collaboration with the Clinical Documentation Specialist; updates working DRG as appropriate.

  • Timely submission of clinical reviews to payors responding to requests for initial/concurrent clinical information; documents correspondence in the Care Manager/Cerner software.

  • Appropriately initiates consultation/referral to secondary review (UR Medical Director/Physician Advisor) for admission medical necessity and continued stay reviews. 

  • Confirms payor authorization and timely submits request for additional information.

  • Promptly refers concurrent denials to the UR Medical Director/Physician Advisor for appeal as needed.  Able to complete reconsideration in eQHealth and a denial appeal packet for managed care payors.

  • Clear and efficient documentation of clinical reviews in the Clinical Review screen of Care Manager/Cerner.

  • Documents authorizations, avoidable days, and other relevant information for purposes of tracking/trending.

  • Serves as a utilization/resource management resource to physicians, staff, and other members of the health care team including community agencies.

  • Supports and facilitates hospital goals for capacity management and length of stay (LOS). 

  • Works with the multidisciplinary healthcare team to develop, activate and efficiently facilitate patient treatment and discharge plans. Evaluates the potential for unplanned readmissions.

  • Demonstrates knowledge in admission and continued stay criteria for inpatient and observation in order to facilitate proper patient placement across the healthcare continuum.

  • Demonstrates and encourages positive interpersonal relations with the patient/family, physicians, community agencies, and other members of the health care team.  Maintains open communication.

  • Leads and/or participates in weekly unit interdisciplinary discharge meetings (ICPC) along with hospital LOS meetings for complex patients.

  • Maintains clinical competency and current knowledge of community resources and payor requirements to perform job responsibilities.

  • Assists with departmental Performance Improvement initiatives

  • Maintains computer proficiency to perform/complete work assignments including the electronic medical record, Care Manager, and Outlook e-mail/calendar management.

  • Exhibits organizational skills, flexibility, and teamwork.

  • Provides necessary coverage and assistance with other duties within the department when needed.


What You Will Need:

  • Ability to communicate effectively with diverse populations.

  • Interpersonal skills that promote teamwork

  • Critical thinking and problem-solving skills

  • Effective organizational skills

  • Proficiency in the daily use of standard office equipment such as computer, phone, fax, copier, etc. and sill in utilizing Microsoft Work and Outlook tools

  • Minimum 2 years recent acute care experience

  • Minimum of an additional 2 years of experience in healthcare related fields

  • Active Florida State License as a Registered Nurse

Job Summary:

Under general supervision of the Supervisor of Case Management and/or Director, in collaboration with the RN case manager, social workers, physicians and interdisciplinary team, the RN Utilization Review Nurse ensures patient progression through the continuum of care in an efficient and cost-effective manner.  The UR nurse proactively coordinates case reviews for admission and continued stay criteria as well as retrospective reviews as needed.  Care coordination, utilization review and management, and an understanding of discharge planning are accountabilities of this role.  The goals of the UR nurse include targets of LOS, accurate use of observation status, denial management, and DRG assurance.  Education is provided to physicians and other members of the team on the issues related to utilization review including inappropriate admissions and placements.  Payer based requests regarding individual members are fulfilled, where appropriate and pertinent. The Utilization review nurse adheres to departmental and organizational goals, objectives, standards of performance and policies and procedures, continually ensuring quality patient care and regulatory compliance.  Actively participates in outstanding customer 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.

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