About the position
The Registered Nurse (RN) in Utilization Review at Ascension Sacred Heart Pensacola plays a crucial role in ensuring that patients receive appropriate healthcare services while adhering to established medical necessity and reimbursement policies. This part-time position is scheduled for either two 12-hour shifts or three 8-hour shifts during weekdays, with no weekend work required, although holiday rotations are expected. The RN will be part of the Utilization Management department, which focuses on optimizing patient care through effective case management and utilization review processes. In this role, the RN will be responsible for reviewing admissions and service requests within their assigned unit to determine the medical necessity of services provided. This includes conducting prospective, concurrent, and retrospective reviews to ensure compliance with reimbursement policy criteria. The RN will also provide case management and consultation for complex cases, assisting departmental staff with issues related to coding, medical records, precertification, and claim denials or appeals. Additionally, the RN will assess and coordinate discharge planning needs in collaboration with healthcare team members, ensuring that patients transition smoothly from hospital to home or other care settings. The position may also involve preparing statistical analyses and utilization review reports as necessary, as well as overseeing compliance with federally mandated and third-party payer utilization management rules and regulations. This role is vital in maintaining the quality of care while managing costs effectively within the healthcare system.
Responsibilities
- Provide health care services regarding admissions, case management, discharge planning and utilization review.
- Review admissions and service requests within assigned unit for prospective, concurrent and retrospective medical necessity and/or compliance with reimbursement policy criteria.
- Provide case management and/or consultation for complex cases.
- Assist departmental staff with issues related to coding, medical records/documentation, precertification, reimbursement and claim denials/appeals.
- Assess and coordinate discharge planning needs with healthcare team members.
- May prepare statistical analysis and utilization review reports as necessary.
- Oversee and coordinate compliance to federally mandated and third party payer utilization management rules and regulations.
Requirements
- Current Registered Nurse (RN) license in the state of Florida.
- Experience in utilization review or case management preferred.
- Strong knowledge of medical necessity criteria and reimbursement policies.
- Excellent communication and interpersonal skills to work effectively with healthcare team members.
Nice-to-haves
- Certification in Utilization Review (CUR) or Case Management (CCM) is a plus.
- Experience with electronic health records (EHR) systems.
Benefits
- Paid time off (PTO)
- Various health insurance options & wellness plans
- Retirement benefits including employer match plans
- Long-term & short-term disability
- Employee assistance programs (EAP)
- Parental leave & adoption assistance
- Tuition reimbursement
- Ways to give back to your community
