Location:
Miramar, FloridaWe have an outstanding reputation for providing patient- and family-centered care that exceeds all expectations. Together, we have created an award-winning, nationally-recognized system where every effort is focused on delivering Deeper Caring and Smarter Healthcare throughout our communities. Career opportunities exist on diverse teams across our many facilities where you can search open positions and apply online to join #teamMHSflorida.
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Summary:
The Utilization Management RN uses evidence-based medical necessity screening tools to complete initial and continued stay reviews in determining appropriate level of patient care, appropriateness of tests/procedures, and an estimation of the patients expected length of stay. The Utilization Management RN follows the Utilization Review (UR) process as defined in the Utilization Review Plan in accordance with the CMS Conditions of Participation for Utilization Review.
Weekend and holiday rotation required
10-hour shiftsResponsibilities:
Collaborates with onsite Case Management team regarding patient's discharge readiness.Manages timely communication of pertinent clinical data to support admission, clinical condition, and continued stays.Assists departmental staff with issues related to coding, medical records/documentation, precertification, reimbursement, and claim denials/appeals.Uses medical necessity criteria and reviews medical records to determine patients medical necessity for acute hospitalization at the appropriate level of care.Reviews admissions and service requests for prospective, concurrent, and retrospective medical necessity and/or compliance with reimbursement policy criteria.Prepares statistical analysis and utilization review reports as necessary.Competencies:
ACCOUNTABILITY, ACCURACY, CUSTOMER SERVICE, EFFECTIVE COMMUNICATION, MANAGING WORKLOADS, ORGANIZATION SKILLS, PATIENT AND FAMILY CENTERED CARE, PROBLEM SOLVING, RESPONDING TO CHANGE, STANDARDS OF BEHAVIOR, UTILIZATION REVIEWEducation and Certification Requirements:
Accredited Program: Nursing (Required)Registered Nurse Compact License (RN LICENSE COMPACT) - Compact RN Multistate, Registered Nurse License (RN LICENSE) - State of Florida (FL)Additional Job Information:
Complexity of Work: Requires critical thinking skills, effective communication skills, decisive judgment, and the ability to work with minimal supervision. Current sound clinical knowledge; knowledge of medical literature, research methodology, and financial/reimbursement issues. Knowledge of CMS, commercial payer requirements and hospital financial/reimbursement processes. Ability to work collaboratively and proactively with healthcare teams and other hospital-based interdisciplinary teams. Must be able to work in a stressful environment and take appropriate action.Required Work Experience: Two (2) years of nursing experience. One (1) year of experience in utilization management or case management preferred.Other Information: Certification in utilization management and/or case management preferred.Working Conditions and Physical Requirements: Bending and Stooping = 40%Climbing = 0%Keyboard Entry = 100%Kneeling = 0%Lifting/Carrying Patients 35 Pounds or Greater = 0%Lifting or Carrying 0 - 25 lbs Non-Patient = 40%Lifting or Carrying 2501 lbs - 75 lbs Non-Patient = 0%Lifting or Carrying > 75 lbs Non-Patient = 0%Pushing or Pulling 0 - 25 lbs Non-Patient = 0%Pushing or Pulling 26 - 75 lbs Non-Patient = 0%Pushing or Pulling > 75 lbs Non-Patient = 0%Reaching = 60%Repetitive Movement Foot/Leg = 0%Repetitive Movement Hand/Arm = 60%Running = 0%Sitting = 80%Squatting = 0%Standing = 0%Walking = 0%Audible Speech = 80%Hearing Acuity = 80%Smelling Acuity = 0%Taste Discrimination = 0%Depth Perception = 80%Distinguish Color = 40%Seeing - Far = 40%Seeing - Near = 80%Bio hazardous Waste = 0%Biological Hazards - Respiratory = 0%Biological Hazards - Skin or Ingestion = 0%Blood and/or Bodily Fluids = 0%Communicable Diseases and/or Pathogens = 0%Asbestos = 0%Cytotoxic Chemicals = 0%Dust = 60%Gas/Vapors/Fumes = 0%Hazardous Chemicals = 0%Hazardous Medication = 0%Latex = 0%Computer Monitor = 80%Domestic Animals = 0%Extreme Heat/Cold = 0%Fire Risk = 0%Hazardous Noise = 0%Heating Devices = 0%Hypoxia = 0%Laser/High Intensity Lights = 0%Magnetic Fields = 0%Moving Mechanical Parts = 0%Needles/Sharp Objects = 0%Potential Electric Shock = 0%Potential for Physical Assault = 0%Radiation = 0%Sudden Decompression During Flights = 0%Unprotected Heights = 0%Wet or Slippery Surfaces = 0%Shift:
DaysDisclaimer: This job description is not intended, nor should it be construed to be an exhaustive list of all responsibilities, skills, efforts or working conditions associated with the job. It is intended to indicate the general nature and level of work performed by employees within this classification.
Wages shown on independent job boards reflect market averages, not specific to any employer. We encourage candidates to talk to their Memorial Healthcare System recruiter to discuss actual pay rates, during the hiring process.
Memorial Healthcare System is proud to be an equal opportunity employer committed to workplace diversity.
Memorial Healthcare System recruits, hires and promotes qualified candidates for employment opportunities without regard to race, color, age, religion, gender, gender identity or expression, sexual orientation, national origin, veteran status, disability, genetic information, or any factor prohibited by law.
We are proud to offer Veterans Preference to former military, reservists and military spouses (including widows and widowers). You must indicate your status on your application to take advantage of this program.
Employment is subject to post offer, pre-placement assessment, including drug testing.
If you need reasonable accommodation during the application process, please call (M-F, 8am-5pm) or email
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