Location Address: 301 Memorial Medical Parkway Daytona Beach, FL 32117
Top Reasons to Work at AdventHealth
Great benefits such as: Educational Reimbursement
Career growth and advancement potential
High quality of life with low cost of living
Full-Time / Days
You Will Be Responsible For:
Coordinates and supports clerical and administrative activities of the Utilization Management team
Collaborates and communicates with payor via phone, fax or payor portal
Submits clinical reviews to payors
Provides information to payors supporting admission /continued stay
Manages requests submitted from payors
Provides discharge dates to payors
Submits copies of UM activities to payors, as needed
Tracks and monitors requests through EMR
Ensures incoming requests are responded to promptly and accurately
Obtains and enters authorization numbers from payors
Verifies up-to-date concurrent authorizations for in-house patients
Reviews and monitors accounts to ensure proper documentation of benefits and authorizations have been completed in required fields and notes
Supports concurrent denials process
Assists in coordinating Peer-to-Peer discussions with the payor for Physician Advisors, Attending Physicians and UM RNs
Updates patient demographic/patient type/coverage, as needed
Assists UM Coordinator in managing central fax (Vyne)/email accounts (Central Repository), as needed
Communicates with all members of the Interdisciplinary Team (i.e., nurses, physicians, etc.), as needed
Assists department leadership with quality audits as needed
Timely escalates cases requiring clinical expertise to UM RNs
Interacts with physicians, physician office personnel, and/or care management departments on an to assure resolution of issues, as needed
Provides timely and continual coverage of assigned work area in order to ensure all accounts are completes
Monitors daily discharge reports to assure all patient stay days are authorized
Maintains a working knowledge of payor contracts and regulatory requirements
Adheres to the policies, procedures, rules, regulations, and laws of the hospital and federal and state regulatory bodies
Communicates and collaborates with Patient Financial Services (PFS) and Health Information Management (HIM) to render appropriate information needed to secure reimbursement, as needed
Collaborates with Care Management team to ensure payor compliance regulations (i.e. Condition Code 44)
Adheres to HIPAA regulations by verifying pertinent information to determine caller authorization level before releasing account information.
Completes any other tasks within department guidelines.
What You Will Need:
Knowledge of Care Management processes / workflows
High School diploma or GED
Two (2) years’ experience in Patient Access, Revenue Cycle Operations, Pre-Access, or related department.
Associate degree and/or higher-level education, or completed coursework, in Health Services Administration or other related medical or business field
The Utilization Management (UM) Specialist works under the direction of the Utilization Management Manager and supports the Utilization Management team with Emergency, Observation and Inpatient visits. The UM Specialist is responsible for providing clerical assistance to the Utilization Management Nurses (UM RN) to assist with verification of benefits, authorization procurement and other assigned tasks as needed. The UM Specialist is responsible for collaborating with the UM RN and other members of the interdisciplinary team (i.e. Physicians, Care Managers, Social Workers, etc.) or interdependent departments (i.e. Patient Access, Billing, etc.) to ensure unnecessary delays in patient care, discharge or billing.
The UM Specialist will serve as the first point of escalation for payors requiring assistance in gaining additional or missing information to support authorization. The UM Specialist will be responsible for ensuring procurement of authorization upon admission and discharge as well as, accuracy of authorization information. The UM Specialist will ensure timely escalation of barriers to authorization requiring clinical expertise and assist in coordination of Peer-to-Peer discussions with the payor.
At AdventHealth, Extending the Healing Ministry of Christ is our mission. It calls us to be His hands and feet in helping people feel whole. Our story is one of hope — one that strives to heal and restore the body, mind and spirit. Our more than 80,000 skilled and compassionate caregivers in hospitals, physician practices, outpatient clinics, urgent care centers, skilled nursing facilities, home health agencies and hospice centers are committed to providing individualized, wholistic care.