REQUIREMENTS:

• Associates Degree in Nursing or Diploma RN
• Active Florida State license as RN
• Two (2) years acute care experience required. Behavioral health experience preferred.
• Ability to work a 5:30am-2pm schedule.

• Facilitate optimal reimbursement through certification process. Conduct concurrent admission and continued stay reviews based on utilization review criteria. Obtain initial certifications for urgent and emergent admissions with zero error rate. Obtain continued stay certification with zero error rate.
• Follow-up of all outstanding cases. Communicate 100% of identified case problems to appropriate level. Assess presence of Severity of Illness/Intensity of Service criteria.
• Participate as active partner with Physician, Nursing, and Social Services in treatment team. Refer consults with Social Services to promote appropriate continued stay or discharge. Refer to and consults with other internal staff as needed to facilitate accurate documentation and assure appropriate, timely discharge
• Communicate 100% of concurrent denial case status to Social Services and attending Physician. Check Physician order on chart for match to billing status. Contact Physician to obtain order for clarification of appropriate patient status.
• Communicate with third party payers by providing clinical information (via e-mail, phone or fax) in accordance with established standards, policies and procedures.
• Enter authorization and days approved data into financial and clinical information systems to facilitate hospital billing.
• Ensure all peer reviews are completed according to insurance specifications.
• Audits Medicare charts according to LCD standards. Ensures Medicare certifications are timely and accurate. Report’s findings to appropriate parties. Makes recommendations for solution.
• Manage all denied days be completing appeal letters with copies of patient chart within 14 days of appeal. Follow-ups on all appeals for resolution. Maintains denial log.
• Works within the organization’s utilization management plan in accordance with the mission and strategic goals of the organization, federal and state law and regulations, and accreditation standards
• Reviews payer contracts and regulatory requirements on an on-going basis
• Conducts concurrent reviews, prepares and presents reports and communicates pertinent information to leadership team when needed