RN Case Manager/Utilization Specialist
7 days ago
Salary: $65,000 - $90,000 per year (based on experience)
About the JobWe are seeking a highly skilled and experienced Registered Nurse to join our team as a RN Case Manager/Utilization Specialist. As a key member of our healthcare team, you will play a vital role in promoting effective use of outpatient hospital and clinic resources.
Responsibilities- Case Management: Assist with developing comprehensive case management plans addressing patient/family needs.
- Documentation Review: Audit documentation and denied claims, ensuring compliance with documentation requirements and assisting in resolving medical necessity pre- and post-payment issues.
- Patient Interaction: Interact with patients and family members, physicians, nurses, and other physician office staff, business office, pharmacy, insurance companies, and other departments to facilitate delivery of quality patient care.
- Auditing and Appeals: Audit accounts when preauthorization has been denied for outpatient services and determine process for appeal, facilitating physician-to-physician case reviews as needed.
- Collaboration: Collaborate with representatives from PFS/appeals department to appropriately facilitate all appeals with Administrative Law Judge.
- Medical Necessity: Conduct audits of orders written to ensure medical necessity criteria are met, reviewing claim denials and collaborating with physicians to establish medical necessity.
- Trend Identification: Identify trends within the outpatient departments and provide staff education for performance improvement.
- Ongoing Education: Provide ongoing education to physicians and staff regarding medical necessity criteria and reimbursement guidelines.
- Education: Bachelor's degree in Nursing; completion of an accredited RN education/training program is also acceptable.
- Licensure: Maintain current RN license in the state of Florida.
- Experience: Five years' acute care experience or five years' experience in case management, hospital discharge planning, risk management, quality assurance, and/or utilization review.
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Ocoee, Florida, United States Health Central Hospital Full timeJob SummaryWe are seeking an experienced RN Case Manager/Documentation Specialist to join our team at Health Central Hospital. As a key member of our outpatient department, you will be responsible for ensuring the medical necessity of services and facilitating quality patient care.About the RoleThis is a challenging and rewarding opportunity for a highly...
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