Our promise to you:

Joining AdventHealth is about being part of something bigger. It’s about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit. AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding that together we are even better.

Schedule: PRN

Shift: 10 hour shift/weekend rotation every four weeks

Location: AdventHealth Hendersonville 100 Hospital Drive Hendersonville NC 28792

The role you’ll contribute: Responsible for assuring the receipt of high quality, cost efficient medical outcomes for those enrollees identified as having the need for inpatient and or outpatient precertification / preauthorization. Complete ongoing clinical and concurrent reviews as indicated. Assist Discharge Planners as needed with Facility Transfers. Provide discharge plan to Payors. Assist the Billing office and Denials Specialist with clinical information as needed for the purpose of reimbursement.

The value you’ll bring to the team:

• Discharge planning; connect patients to rehab, home health, and other community resources
• Accurately follows up on Utilization Review activities, with documentation in the appropriate format
• Communicates accurately and efficiently with business office and other relative departments regarding insurance benefits and UR references for each patient.
• Initiates all initial clinical reviews per protocol in a timely manner
• Complete concurrent clinical reviews per utilization management policy
• Initiates all required pre-certs within 24-48 hours per contractual agreement
• Understands and participates in weekly unit treatment team meetings
• Follows up appropriately on commercial payer denials
• Is knowledgeable of payer source criteria for coverage of acute care services.
• Provides discharge planning expertise in collaboration with other health care professionals
• Acts as an advocate for an individual’s health care needs
• Understands the psychological disease process and utilizes this knowledge to recommend resources to meet the needs of the patient
• Participates with the medical, nursing and social work team to assess post hospital medical, social and financial needs
• Participates with the team to evaluate the quality of services and make recommendations for changes in the plan of care.
• Maintains familiarity with laws regulations and interpretation of the same as it relates to utilization review and discharge planning.
• Demonstrated the understanding of requirements for pre-certification process by payers.
• Participates with the team to identify cases that would benefit from alternative care and make recommendations as needed.
• Acts as a liaison between the third party payers and the health care team
• Coordinates with third party payers to review progress toward established treatment goals. Cooperates with and provides concurrent review information to Insurance Companies as requested/ per contractual agreements.

The expertise and experiences you’ll need to succeed:

• Current and valid license to practice as a Registered Nurse (AND or BSN) required.
• Excellent interpersonal communication and negotiation skills
• Strong analytical, data management, and computer skills
• Strong organizational and time management skills, as evidenced by capacity to prioritize multiple tasks and role components
• Must be able to demonstrate knowledge and skills necessary to provide appropriate status recommendations. Must demonstrate knowledge of the principles of growth, development, and disease states as it relates to the different life cycles.
• Demonstrates ability to understand differences between notification, reference, and authorization numbers. Maintains up-to-date concurrent authorizations for in-house patients. Accesses and reviews payer portals for authorization numbers in collaboration with department assistants; ensures proper update of authorization fields within EMR accordingly, delegating appropriate tasks to support staff.
• Familiarizes self with authorization requirements for assigned payers, based on payer matrix. Assists in assuring proper patient status authorization, by reviewing patient admission status within the electronic health record and matching with the correct authorization. Expedites communication with insurance contacts to assure timely authorization is received to avoid unnecessary denials.
• Ability to navigate and utilize other related software and databases to perform required actions that encompass Utilization Management.
• Demonstrates strong analytical, problem solves skills and the ability to analyze complex data
• Promotes individual professional growth and development by meeting requirements for mandatory/continuing education, skills competency, supports department-based goals which contribute to the success of the organization; serves as a resource to less experienced staff.