RN Case Manager/Utilization Specialist

7 days ago


Ocoee, Florida, United States Health Central Hospital Full time
Job Title: RN Case Manager/Utilization Specialist

Salary: $65,000 - $90,000 per year (based on experience)

About the Job

We 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.
Requirements
  • 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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