RN Utilization Manager at Healthcare Recruitment Partners

RN Utilization Management Nurse Frontline OpportunityGreater Orlando FloridaThe RN Utilization Management Nurse uses clinical expertise by analyzing patient records to determine legitimacy of hospital admission treatment and appropriate level of care. The Utilization Management RN leverages the algorithmic logic of the platform utilizing key clinical data points to assist in status and level of care recommendations. The UM RN is responsible for documenting findings based on department and regulatory standards. When screening criteria does not align with the physician order or a status conflict is indicated the Utilization Management Nurse is responsible for escalation to the Physician Advisor or designated leader for additional review as determined by department standards. Additionally the RN Utilization Management Nurse is responsible for denial avoidance strategies including concurrent payer communications to resolve status disputes.Qualifications:Registered Nurse ADN or BSN required3 years Acute Care Clinical Nursing experience required2 years Utilization Management experienceExcellent interpersonal communication and negotiation skillsStrong analytical data management and computer skillsStrong organizational and time management skills as evidenced by capacity to prioritize multiple tasks and role componentsPreferred:Bachelor of Science in Nursing or other related BS or BA in addition to NursingClinical experience in acute care facility greater than five years4 years Utilization Management within Acute Care Hospital settingResponsibilities: Monitors admissions and performs initial patient reviews within 24 hours of admission; and when warranted by length of stay utilization review plan and/or best practice guidelines on a continuing basisPerforms pre-admission status recommendation in Emergency Department or elective procedure settings as assigned to communicate with providers status guidance based on available informationMaintains thorough knowledge of payer guidelines familiarity with payer processes for initiating authorizations and following through accordingly to prevent loss of reimbursement including the management of concurrent and pre-bill denialsEnsuring all benefits authorization requirements and collection notes are obtained and clearly documented on accounts in the pursuit of timely reimbursement within established timeframes to avoid denialsWorks collaboratively and maintains active communication with physicians nursing and other members of the multi-disciplinary care team to effect timely appropriate management of claimsUtilizes advanced conflict resolution skills as necessary to ensure timely resolution of issuesCollaborates with the physician and all members of the multidisciplinary team to facilitate care for designated case load; monitors the patients progress intervening as necessary and appropriate to ensure that the plan of care and services provided are patient focused high quality efficient and cost effective; facilitates the following on a timely basis Communication to third party payors and other relevant information to the care teamAssignment of appropriate levels of careAbility to work independently and exercise sound judgment in interactions with physicians payors patients and their familiesCompletion of all required documentation in the Cortex platform and in the systems electronic health recordEscalating otherwise unresolved status conflicts appropriately and timely to the physician advisor to avoid concurrent denialsCollaborates with medical staff nursing staff payor and ancillary staff to eliminate barriers to efficient delivery of care in the appropriate settingCommunicates with all parties (i.e. staff physicians payers etc.) in a helpful and courteous manner while extending exemplary professionalismAnticipates and responds to inquiries and needs in an assertive yet courteous manner. Demonstrates positive interdepartmental communication and cooperationActively participates in clinical performance improvement activitiesAssists in the collection and reporting of resource and financial indicators including LOS cost per case avoidable days Resource Utilization readmission rates concurrent denials and appealsUses data to drive decisions and plan/implement performance improvement strategies related to care management for assigned patients including fiscal clinical and patient satisfaction dataCollects analyzes and addresses variances from the plan of care/care path with physician and/or other members of the healthcare teamUses concurrent variance data to drive practice changes and positively impact outcomesCollects delay and other data for specific performance and/or outcome indicators as determined by Director of Care ManagementDocuments key clinical path variances and outcomes which relate to areas of direct responsibility (e.g. discharge planning) Uses pathway data in collaboration with other disciplines to ensure effective patient management concurrentlyEnsures requested clinical information has been communicated as requestedMonitors daily discharge reports to assure all patient stay days are authorizedFollows up with insurance carrier to obtain complete authorization to avoid concurrent or retrospective denialsCommunicates with the other departments / team members for resolutions of conflicts between status and authorizationEvaluates clinical review(s) and physician documentation for at-risk claims; performs additional reviews and/or include pertinent addendums to fortify/reinforce basis for accurate claim reimbursementDemonstrates a strong understanding of medical necessity (i.e. severity of illness intensity of service risk) level of acuity and appropriate plan of careInteracts with physicians physician office personnel and/or Case Management departments on an as-needed basis to assure resolution of pending denials which have been referred to the physician for peer-to-peer review with the Medical Director of the insurance carrierHow to Apply:Interested candidates please submit your resume to Michelle Boeckmann at . Visit for more details and additional opportunities. Feel free to share these contact details with anyone interested in Case Management or Utilization Management roles.Contact: Michelle Boeckmann President Case Management Recruitment Direct Dial: Best Professional Recruiting Firms Forbes 2025Top 10 U.S. Search Firm Executive Search ReviewMember of the Sanford Rose Associates network of officesRequired Experience:Manager Key Skills Restaurant Experience,Customer Service,Employee Evaluation,Management Experience,Math,Employment & Labor Law,Sanitation,Leadership Experience,P&L Management,Mentoring,Supervising Experience,Restaurant Management Employment Type : Full Time Experience: years Vacancy: 1