Utilization Review Market Lead - Registered Nurse RN

HCA West Florida is a comprehensive network of hospitals, outpatient surgery and diagnostic imaging facilities, physician practices, medical education and training programs and a complete continuum of specialized health programs and services that meet the healthcare needs of residents and businesses in West Florida communities.

In 2015, we treated more than 1.2 million patients. Our parent company, HCA, is the nation's leading provider of healthcare services. HCA West Florida affiliated facilities include, 16 hospitals on 18 Campuses, 14 ambulatory surgery centers, diagnostic imaging facilities and occupational health sites, an integrated regional lab, and a consolidated service center.

The Division UR Lead supports the WFD Case Management departments in admission/concurrent reviews adhering to medical necessity and Corporate Compliance guidelines. This virtual role reviews patient admissions and concurrent stays using hospital software tool and other information sources and integrates patient clinical data with the appropriate selection of Medical Necessity Criteria. The CM will expedite timely response on cases requiring external physician advisor reviews and/or follow up of cases with status determination after normal business hours. The CM will be responsible to contact the payers and documentation of the authorized days in conjunction with available support staff. As reviews are completed, if issues related to conditions not clearly documented as present on admission (POA) placing risk for hospital acquired conditions (HAC) will be communicated back to the hospitals (CDI, CM and Quality) for timely intervention. In addition, patients that require special needs, such as social work intervention will be referred to the hospital team. This role will also involve becoming a subject matter expert in Medical Necessity criteria and Utilization Review. As such travel may be involved to the hospitals as needed for training.
RN required and active license. ACM, CCM or CPUR also preferred

Graduate of an accredited School of Nursing. Bachelor of Science in Nursing degree preferred

Experience and Qualifications:
  • Performs in accordance with delineated job responsibilities and satisfactorily completes a yearly evaluation based on these responsibilities.
  • 4 years experience in acute care setting and/or insurance in Case Management required
  • Preferred experience in education and/or Interqual/Milliman Certified instructor. Ability to orient new CM in appropriate use of Medical Necessity tool.
  • Demonstrated ability for process improvement in the design and standardization of workflow related to the admission UR process for standardization across all of WFD. This will also lead to competency/new orientation checklist development.
  • Demonstrated ability to mentor members of the team and lead process changes and communicate these changes in a positive growing experience for all case management team members.
  • Ability to present to senior team leaders at the hospital and division level as requested with involvement in measurement outcomes.
  • Ability to work with the Division Case Management team to initiate change to impact WFD and Corporate goals in the area of denial reduction and LOS opportunities.
  • Demonstrates analytical and critical thinking abilities with pro-active decision making and negotiation skills.
  • Excellent communication skills (oral and written) and customer service oriented
  • Ability to establish collaborative and effective working relationships.
  • Ability to work with data for trends and use of reports.
  • Ability to travel to the WFD hospitals and division as needed.

Share this Job

Other Locations For This Job