Utilization Management Specialist

All the benefits and perks you need for you and your family: 

·Paid Days Off from Day One 
·Student Loan Repayment Program 
·Career Development 
·Whole Person Wellbeing Resources 
·Mental Health Resources and Support

Our promise to you: 

Joining AdventHealth is about being part of something bigger. It’s about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit. AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding thattogetherwe are even better.

Schedule: Full Time

Shift: Days 

The community you’ll be caring for:AdventHealth Division

·AdventHealth Pepin Heart Institute, known across the country for its advances in cardiovascular disease prevention, diagnosis, treatment and research.
·Surgical Pioneers – the first in Tampa with the latest robotics in spine surgery
·Building a brand new, six story surgical and patient care tower which will ensure state of the art medical and surgical car for generations to come
·Awarded the Get With The Guidelines – Stroke GOLD Quality Achievement Award from the American Heart Association/American Stroke Association and have been recognized as a recipient of their Target: Stroke Honor Roll for our expertise in stroke care. We have also received certification by The Joint Commission in collaboration with the American Stroke Association as a Primary Stroke Center.

The role you’ll contribute:

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.

The value you’ll bring to the team:

·  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.