Location Address: 701 West Plymouth Avenue, Deland Florida 32720
Top Reasons to Work at AdventHealth Deland
Career growth and advancement potential
High quality of life with low cost of living
You Will Be Responsible For:
Utilizes daily census reports, bedrosters, LOS reports, patient admission data, insurance census reports by payor, transfer and discharge reports to establish Utilization Review status for assigned population.
Performs Case Review –Workload is prioritized according to the last review date, patient’s clinical status, patient’s LOS, and payor status.
Assists therapists with discharge planning.
Initial chart review:
Maintains knowledge of review criteria used in the utilization management process and applies it objectively.
Maintains a system for monitoring admissions and continued stay reviews.
Will complete initial chart review, if not already completed.
Certifies admissions/ continued stays meeting criteria and assigns length of stay.
Utilization Review Nurse will communicate with the multidisciplinary team and ancillary departments regarding treatment concerns, timing of treatments, or delay in care issues. Chart review data – MD orders, progress notes, Cerner notes, daily assessment data, lab, radiology reports, therapy data, and consult reports are recorded.
Once the patient is through the initial review process, Continued Stay review will report data gathered from the time of the last documented chart review to the present.
Elicit information from behavioral health unit staff to help in evaluating patient need for acute care.
Monitors level of care appropriateness and documentation to support level of care. Encourages efficient use of days and resources.
Interacts with members of the multidisciplinary team to facilitate continuity in patient care for effective and timely discharge planning.
The Utilization Review Nurse is responsible for communicating to the physician when a patient does not meet criteria for admission and continued stay.
The Utilization Review Nurse will then document the physician response in the departmental electronic review module.
Serves as a resource to physicians and unit staff in areas concerning Utilization management, reimbursement, or issues that may negatively impact the efficiency and effectiveness of patient care.
Acts as a liaison person and interfaces with representatives from insurance and review agencies.
Several insurance agencies accept phone reviews only. Utilization Review Nurse will communicate review information to the insurance companies by fax, phone, or electronic submission.
When a precertification number is confirmed with the insurance agency, it is then documented on the insurance log and communicated to the admitting office and noted in the patient account.
Communicating with the insurance provider also involves the exchange of discharge planning needs. This is then communicated to the appropriate individual setting up the discharge planning needs of the patient.
At least 3 years experience in psychiatric nursing.
Currently licensed by the State of Florida
Responsible for reviewing and evaluating cases for admission, continued stays, and retrospective reviews in accordance with the utilization management plan. Ensures that quality clinical services and financial outcomes are achieved within established time frames. Promotes a positive approach for case management and nurtures open communication between utilization management and the health care team concerning the level of patient care needed. Ensures that the patient meets admission and continued stay criteria. Confers with private utilization and managed care agencies to provide clinical information and to ensure reimbursement for services provided to patient. The utilization review nurse will clarify any disputed charges from an insurance company by performing a thorough review of the chart. Will review denials with physicians as necessary to formulate appeals. It is the responsibility of the Utilization Review Nurse to adhere to the Florida Hospital Corporate Compliance Plan, to the rules and regulations of all applicable local, state, and federal agencies and to the standards of all accrediting bodies. The Utilization Review Nurse demonstrates competency within the scope of practice, as appropriate to the ages of the patient services and maintains knowledge of growth and development with an understanding of the range of treatment needed by these patients.
At AdventHealth, Extending the Healing Ministry of Christ is our mission. It calls us to be His hands and feet in helping people feel whole. Our story is one of hope — one that strives to heal and restore the body, mind and spirit. Our more than 80,000 skilled and compassionate caregivers in hospitals, physician practices, outpatient clinics, urgent care centers, skilled nursing facilities, home health agencies and hospice centers are committed to providing individualized, wholistic care.