Pool Utilization Review Registered Nurse, Case Management

Baptist Health has a commitment to strengthening the compassionate care we provide. With the addition of Boca Raton Regional Hospital, Baptist Health is able to provide the Palm Beach community expanded access to healthcare services.
Boca Raton Regional Hospital is an advanced tertiary medical center with 400 beds and is a recognized leader in Cardiovascular Care, Oncology, Women's Health, Orthopedics, Emergency Medicine and the Neurosciences, all of which offer state-of-the-art diagnostic and imaging capabilities. The Hospital is now a part of Baptist Health South Florida, the largest healthcare organization in the region, with 12 hospitals, more than 24,000 employees, 4,000 physicians and 100 outpatient centers, urgent care facilities and physician practices spanning across Miami-Dade, Monroe, Broward and Palm Beach counties. Baptist Health has internationally renowned centers of excellence in cancer, cardiovascular care, orthopedics and sports medicine, and neurosciences. A not-for-profit organization supported by philanthropy and committed to its faith-based charitable mission of medical excellence, Baptist Health has been recognized by Fortune as one of the 100 Best Companies to Work For in America and by Ethisphere as one of the World’s Most Ethical Companies.

Everything we do at Baptist Health, we do to the best of our ability. That includes supporting our team with extensive training programs, millions of dollars in tuition assistance, comprehensive benefits and more. Working within our award-winning culture means getting the respect and support you need to do your best work ever. Find out why we’re all in for helping you be your best.

Description:

The purpose of this position is to conduct initial, concurrent, retrospective chart review for clinical financial resource utilization. Coordinates with healthcare team for optimal/efficient patient outcomes, while decreasing length of stay (LOS) and avoid delays and denied days. They are accountable for a designated patient caseload and provides intervention, coordination to decrease avoidable delays, denial of reimbursement. Specific functions within this role include: Screens pre-admission, admission process using established criteria for all points of entry. Facilitates communication between payers, review agencies, healthcare team. Identify delays in treatment or inappropriate utilization and serves as a resource. Coordinates communication with physicians. Identify opportunities for expedited appeals and collaborates resolve payer issues. Ensures/Maintains effective communication with Revenue Cycle Departments. Estimated pay range for this position is $45.00 / hour depending on experience.

Qualifications:

Degrees: Associates Licenses & Certifications: AAMCN Utilization Review Professionals McKesson Certified Professional in Utilization Management ABMCM Certified Managed Care Nurse ANCC Nursing Case Management Registered Nurse NACCM Care Manager Certified CCMC Case Manager ACMA ACM Certification CDMS Certified Disability Management Specialist RNCB Certified Rehabilitation Registered Nurse NBCC Certification in Continuity of Care, Advanced Additional Qualifications: RNs hired prior to 7/1/2019 with an Associates Degree in Nursing are not required to have a BSN to continue their non-leadership role as an RN, however, they are required to complete the BSN within 5 years of job entry date. A Utilization Review or Case Management Certification required within 12 months of hire. 3 years of hospital clinical experience preferred. Excellent written, interpersonal communication and negotiation skills. Strong critical thinking skills and the ability to perform clinical/chart review abstract information efficiently. Strong analytical, data management and computer skills. Strong organizational and time management skills, as evidenced by capacity to prioritize multiple tasks and role components. Current working knowledge of payer and managed care reimbursement preferred. Ability to work independently and exercise sound judgment in interactions with the health care team and patients/families. Knowledgeable in local, state, and federal legislation and regulations. Ability to tolerate high volume production standards. Minimum Required Experience:
EOE