RN CM UR Specialist PT Night in Orange City, FL at Florida Hospital Fish Memorial

Date Posted: 9/15/2018

Job Snapshot

  • Job Schedule
  • Job Category
  • Date Posted:
  • Job ID:
  • Job Function
    Care Management
  • Travel
  • Shift
    3 - Night
  • AHS Zone
    1-Shared Services
  • Organization
    Florida Hospital Fish Memorial

Job Description


Work Hours/Shifts

PT /Night

Florida Hospital Fish Memorial

For a young hospital built in 1994, Florida Hospital Fish Memorial has a long history dating back to 1952. Beginning as a humble, 50 bed facility more than six decades ago, we’ve grown to become one of Volusia County’s most comprehensive and trusted healthcare resources. With Florida Hospital's tremendous resources and expertise, our community hospital has continued to thrive due to constantly improving advanced medical technologies and experienced clinical talent.

Through our dedication to excellence we have been recognized as Orlando Sentinel’s "Top 100 Companies for Working Families" for 9 consecutive years. We also received the Performance Achievement Award from the Medicare Quality Improvement Organization of Florida, as well as, the 24th Annual Commissioner’s Business Recognition Award from the Florida Educational Foundation and Florida Department of Education.

As a member of Adventist Health System, Florida Hospital Fish Memorial operates as a not-for-profit organization focused on improving the health of the community it serves. This is a direct reflection of our mission to extend the healing ministry of Christ with skill and compassion." Best of all, it’s just a short trip from some of Florida’s most exciting attractions—and minutes from the beaches in Daytona!



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.

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