Job Information
Health First Utilization Review Nurse in Melbourne, Florida
POSITION SUMMARY
The Utilization Review (UR) nurse performs medical necessity reviews on all payer admissions to determine appropriate admission status and documents all information that relates to insurance reimbursement in appropriate reviews. The UR Nurse utilizes advanced clinical skills to facilitate the provision of care including the appropriate length of stay, patient status management, resource utilization and discharge planning for all hospital admissions. The UR Nurse effectively and efficiently manages a diverse workload in a fast-paced, rapidly changing regulatory environment and regularly collaborates with the Medical Staff, Physician Advisors, Case Managers, Revenue Cycle and other multi-disciplinary teams.
PRIMARY ACCOUNTABILITIES
- Screens all admissions for medical necessity and collaborates with the physician to identify and place the patient at the correct level of care and patient type.
- Coordinates clinical care to include medical necessity, appropriateness of care and resource utilization for admission.
- Communicates with physicians, office staff, health-care team and physician advisors to determine appropriate status and medical necessity.
- Documents in the Electronic Medical Record and other applications that initial and concurrent reviews have been appropriately completed.
- Promotes professional practice through collegial support and interactions.
- Understands revenue operations and closely partners with charge capture and reimbursement analysts as necessary.
- Is an active member of the Utilization Management Committee.
MINIMUM QUALIFICATIONS
- Education: Associate’s Degree in Nursing.
- Licensure: Current, valid State of Florida RN license or endorsement.
- Certification: Current American Heart Association Basic Life Support Healthcare Provider Completion Card upon hire and maintained.
- Work Experience: At least five (5) years of strong clinical experience in an acute care hospital clinical practice area.
- Knowledge/Skills/Abilities: o Strong analytical, data management and computer skills. o Ability to work autonomously and prioritize multiple tasks and role components. o Ability to exercise sound judgment in interactions with physicians, payers, and other customers. o Must be able to work remotely with adequate technology to support and maintain productivity.
PREFERRED QUALIFICATIONS
- Education: BSN or Master’s Degree in a healthcare field
- Certification: Current Case Manager Certification (CCM or ACM)
- Work Experience: Critical, Intermediate or Emergency Department Nursing
- Knowledge/Skills/Abilities: Current working knowledge of care transitions, utilization management, case management and managed care reimbursement
*PHYSICAL REQUIREMENTS (Sedentary) *
- Majority of time involves sitting or standing; occasional walking, bending, stooping • Long periods of computer time or at workstation.
- Light work that may include lifting or moving objects up to 20 pounds with or without assistance.
- May be exposed to inside environments with varied temperatures, air quality, lighting and/or low to moderate noise.
- Communicating with others to exchange information.
- Visual acuity and hand-eye coordination to perform tasks.
- Workspace may vary from open to confined; on site or remote.
- May require travel to various facilities within and beyond county perimeter; may require use of personal vehicle.
Job: *Registered Nurse
Organization: *Holmes Regional Medical Center
Title: Utilization Review Nurse
Location: Florida - Brevard County-Melbourne
Requisition ID: 076106
