RN Utilization Review Manager in New Smyrna Beach, FL at Adventist Health System

Date Posted: 9/19/2018

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 New Smyrna

Job Description

Work Hours/Shifts

Florida Hospital New Smyrna:

Since 1954, Florida Hospital New Smyrna (formerly Bert Fish Medical Center) has served as the community hospital for Southeast Volusia County. Our more than 700 employees use an impressive array of technology and years of knowledge to provide exceptional care for every patient – every day. We offer a wide range of services, including a surgery program, radiology, an oncology center, cardiovascular services, a wound care center, outpatient diagnostic services, and one of the busiest emergency departments of any hospital our size.


You will be responsible for:

  • The Manager or Utilization Management works under the direction of the Director Management to plan, organize, implement and evaluate the utilization management program at Florida Hospital Memorial Medical Center. 
  • This includes Authorizations, Initial Reviews, Concurrent Reviews, Denials and Appeals.  
  • Responsible for review of hospital medical necessity denials, and completes timely submission of all appeals for each level of appeal needed; documents all outcomes appropriately.
  • Responsible for RAC Readiness case review audits, and the tracking of outcomes involving RAC/MAC/MIC/PAC, Commercial Payers, Managed Care, etc. for Florida Hospital Memorial Medical Center.
  • Oversee points of entry access management and front-end denial management processes. 
  • Analyze and monitor metrics to identify trends for process or performance improvement that impact denial rates and reimbursement.
  • Works with the RN care managers, Patient Access, Compliance Nurse Manager Auditor, HIM Staff, CDI staff, Revenue Cycle Team, Care Management Services Physician Advisor (s), Chief Medical Officer and other Medical Staff for educational opportunities to prevent future denials. 
  • Experienced in a supervisory role for utilization review or care management services, managed care services, discharge planning and transitional care planning within a hospital acute care or community –based care setting (s).
What will you need?
  • Current Florida RN license required.
  • Minimum 3 years’ experience in an acute care hospital
  • BS in Nursing or related field
  • Three (3) years’ experience as a hospital Care Manager or Utilization Review Nurse
  • Two (2) years’ utilization review, resource management, and denial management experience

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