RN CM UR Specialist FT Day in Palm Coast, FL at Adventist Health System

Date Posted: 10/25/2018

Job Snapshot

  • Job Schedule
  • Job Category
  • Date Posted:
  • Job ID:
  • Job Function
    Care Management
  • Travel
  • Shift
    1 - Day
  • AHS Zone
    1-Shared Services
  • Organization
    Florida Hospital Flagler

Job Description


Work Hours/Shifts

Full Time, Days

Florida Hospital Flagler

At Florida Hospital Flagler, we’re deeply rooted in the community and strive to extend the healing ministry of Christ in everything we do. Our recently constructed, state-of-the-art hospital in Palm Coast, Florida is equipped with the latest technology, specially trained experts, and advanced care centers. 

Florida Hospital Flagler is owned and operated by Adventist Health System, a faith-based health care organization. Through our Christian mission of hope, health and healing, we strive to promote wellness of mind, body and spirit. At Florida Hospital Flagler, providing the best possible care to our community requires hiring the best possible care providers.


o   The Joint Commission has recognized Florida Hospital Flagler as a Top Performer on Key Quality Measures.

o   Accredited Orthopedic Center of Excellence from The Joint Commission. The Joint Commission has also recognized Florida Hospital Flagler as a Top Performer on Key Quality Measures

o   Recognized by the American Heart Association as a Platinum-Level Fit-Friendly Worksite

o   “A” rating on patient safety from The Leapfrog Group based on our exemplary services, processes and structures.

o   Designated Breast Imaging Center of Excellence according to the American College of Radiology (ACR).

o   Commission on Cancer Accreditation recognizing commitment to provide exceptional care to patients

o   Named a Gallup Great Workplace Award winner for fifth year in a row.

We offer career opportunities in a variety of setting from physician office practices, to acute care, home care and hospice.  If Florida Hospital Flagler sounds like your next career destination, we encourage you to apply today at https://ahs.taleo.net/careersection/95flagler/jobsearch.ftl?lang=en&src=cws-10380



The RN Clinical Case Manager/ Utilization Review Specialist demonstrates professional nursing knowledge and hospital care management services with the ability to perform the necessary primary role(s) of a cross-trained skill-set hospital case manager in listed area (s) of expertise, following hospital and case management policies and processes, to include, but not limited to:

•              Access Management/Utilization Review - Preadmission evaluation or screening

•              Hospital Outpatient Services 

•              Hospital Care Management Services – Acute Care

•              Acute Care Discharge and Transitions

•              Multidisciplinary Care Team(s)

•              Emergency Department Case Management/Community-based Transition

•              Utilization Review, Resource Management: Concurrent Denial Prevention, Denials and

Appeals Management                            

The RN Clinical Case Manager/ Utilization Review Specialist will provide quality utilization case reviews and monitor hospital resource utilization processes for all patients with a primary focus on commercial, managed care insurer plans, and any Traditional Medicare denial audits. Knowledgeable and

able to effectively utilize the medical necessity monitoring tool, hospital approved level of care guidelines, and or any payer specific guidelines or contractual obligations.

Evaluates documentation on patient’s medical necessity elements and appropriateness of scheduled and direct/emergent admissions, surgeries, and other procedures/tests.         

You will be responsible for:

•        Assumes responsibility for high level screening in regard to initial admission assessment and any ongoing concurrent assessment of designated patients as assigned; monitor level of care through communication with direct nursing care givers, care management team, physicians, patient and family members, and other members of the health care team. 

•        Reviews cases for appropriateness of admission and continued stay and appropriate discharge screening for transition plans, physician’s treatment plans and decision making; adhering to the hospital’s policies and procedures, and Case Management Department’s scope of practice and services.

•        Assimilates information obtained from the emergency department visit, information system, ancillary/diagnostic tests, registration, bed management, clinics, admitting physician office, and other facilities to accurately assess patient clinical needs and treatment.

•        Functions as an advocate, and contact person for the care team, patient/family when communicating with payers, and or outside agencies to assure continuity of care, optimal clinical resource outcomes, and appropriate financial management for the patient and the organization.

•        Ensures initial admission reviews are completed and submitted to payer in a timely manner, same admission day or within first working day of admission; obtain certified days for patient’s presenting signs and symptoms and or documented primary diagnosis with treatment plan with the confirmation of level of care and admission status (patient type) appropriateness throughout the patient’s hospital stay.

•        Investigates with resolution of unauthorized clinical days and payment denials by payer for clinical services, same working day; front-end denial prevention prior to patient discharge.

•        Assumes responsibility for the completion of the Florida Medicaid process for patient admission, continued stay, discharge and or post-acute services approval.

What will you need?

•        BS in Nursing or ASN.

•        Minimum 3 years’ Registered Nurse experience in an acute care hospital required.

•        Registered Nurses hired into the case management department with limited experience in Hospital Case Management Program may participate in orientation, education programs, preceptorship and validation of performance for up to a total of three to six months, to include validation of 30/60/90-day (s) employment evaluation.

•        Current Florida RN license

•        Graduate of an accredited School of Nursing

•        Excellent knowledge of the denial/appeal process in regard to Governmental and Third-party payers. 

•        Knowledge of InterQual, Milliman Guidelines, Principles of Managed Care, Computer applications, including but not limited to: Windows, Outlook, Excel and Microsoft Word. 

•        Critical thinking skills.

•        Excellent written and oral communications skills required. 

•        Two (2) years’ experience in utilization review, resource management, care coordination and transitional planning; hospital denials and appeals; experience in managed care, commercial payer guidelines and business care management services 

•        Case Management Certification / Accreditation preferred

This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances.

Location | Organization | Category | Job Function