Utilization Management Registered Nurse (RN) - Remote

About AdventHealth

At AdventHealth, we foster a community centered on holistic care, addressing the wellbeing of body, mind, and spirit. Our mission is grounded in extending the healing ministry of Christ, valuing the diverse experiences and individuality each member brings to our purpose-driven team. Here, you can grow professionally while nurturing your spiritual development.

Job Summary and Responsibilities

• Work four 10-hour shifts on a day schedule (6:30am-5pm or 7am-5:30pm) with weekend rotations.
• Oversee patient admissions and conduct both initial and ongoing medical necessity reviews.
• Maintain in-depth knowledge of payer policies and regulatory rules, and manage denials during concurrent and pre-bill stages to avoid reimbursement losses.
• Engage and communicate with multidisciplinary care teams to provide updates on patient conditions and resolve concurrent denials.
• Foster interdisciplinary collaboration through relationship building.
• Ensure all requested clinical data is communicated effectively, monitor daily discharge reports, and follow-up with insurance providers to secure complete authorizations.

Qualifications and Skills

• Must demonstrate the capability to provide sound patient status recommendations.
• Possess understanding of growth, development, and disease progression across life stages.
• Ability to differentiate among notification, reference, and authorization numbers associated with insurance processes.
• Maintain current concurrent authorizations for in-house patients using daily commercial authorization reports.
• Access payer portals collaboratively with department assistants to verify authorization numbers and update the EMR accordingly, delegating tasks where appropriate to support staff.

Education & Experience

• Associate Degree in Nursing is required; Bachelor's Degree in Nursing is preferred.
• Minimum of 3 years clinical nursing experience is required; 5+ years in an acute care environment is preferred.
• Experience with electronic health records is preferred.
• Background in Utilization Management or Case Management is advantageous.

Licenses and Certifications

• Registered Nurse (RN) license is mandatory.
• Preferred certifications include Accredited Case Manager (ACM) or Certified Case Manager (CCM).

Physical and Legal Requirements

Applicants should be prepared to meet physical work demands as described by the employer. Certain positions require Florida Level 2 background screening including fingerprinting, as mandated by state law.

Compensation and Benefits

• Salary range from $68,132.50 to $119,520.35 annually.
• Comprehensive benefits starting from day one including medical, dental, vision, life, and disability insurance.
• Paid Time Off from the first day of employment.
• 403-B retirement plan.
• Fully paid four weeks of parental leave.
• Opportunities for career development and support for mental health resources.
• Well-being programs focusing on the whole person and pet care benefits.