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Job Details

UM Pre-Procedure Denial Specialist

Location: Fort Myers, FL
Department: UTILIZATION MANAGEMENT
Categories: Nursing
Type: Part-Time
Shift: 8:00 AM-4:30 PM
Schedule: Variable

Description:

Screens procedural cases for compliance with regulatory guidelines. Ensures that reimbursement issues related to medical necessity are resolved to the best of his/her ability. Coordinates the System’s proactive and retrospective denial management processes including but not limited to staff education, collaboration with payors, audits, data analysis, trend identification and improvement efforts. Serves as back up hospital clinical liaison to external review organizations with responsibility for monitoring, tracking and reporting changes, regulatory or otherwise, that impact reimbursement.

Requirements:

Education: Associate Degree in health related profession, with ongoing efforts obtain Bachelor’s Degree.
Experience: Minimum of 3 years clinical experience.
Training: On the job.
License: Currently licensed as an RN in the State of Florida.
Other: Communication and interpersonal skills, basic computer, analytical, grammer and spelling skills. Ability to effectively multi-task responsibilities. Case Management Certification preferred. Require Case Management Certification, ACM, CCM, or CMCN after 2 yrs employment.


External and internal applicants, as well as position incumbents who become disabled, must be able to perform the essential job specific functions (listed within each job specific responsibility) either unaided or with the assistance of a reasonable accommodation to be determined by the organization on a case by case basis. If the requirement is not marked, then it is considered not applicable.
General Requirements (has the ability to…)
Sit - Continually ( i.e. Daily)
Stand - Continually ( i.e. Daily)
Walk - Continually ( i.e. Daily)
Drive - Occasionally (i.e. Monthly)
Climb - Occasionally (i.e. Monthly)
Kneel - Occasionally (i.e. Monthly)
Crouch - Occasionally (i.e. Monthly)
Twist - Occasionally (i.e. Monthly)
Maintain Balance - Continually ( i.e. Daily)
Reach - Continually ( i.e. Daily)

Sensory Requirements (has ability for…)
Far Vision - Occasionally (i.e. Monthly)
Near Vision - Continually ( i.e. Daily)
Seeing Fine Details - Continually ( i.e. Daily)
Hearing Norm Speech - Continually ( i.e. Daily)
Hearing Overhead Pages - Continually ( i.e. Daily)
Telephone use - Continually ( i.e. Daily)

Mental & Emotional Requirements (ability to…)
Cope with high level of stress - Continually ( i.e. Daily)
Make decisions under high pressure - Continually ( i.e. Daily)
Cope with anger/fear/hostility of others in a calm way - Continually ( i.e. Daily)
Manage altercations - Continually ( i.e. Daily)
Concentrate - Continually ( i.e. Daily)
Handle a high degree of flexibility - Continually ( i.e. Daily)
Handle multiple priorities in stressful situation - Continually ( i.e. Daily)
Work alone - Continually ( i.e. Daily)
Demonstrate high degree of patience - Continually ( i.e. Daily)
Adapt to shift work - Occasionally (i.e. Monthly)
Work in areas that are close and crowded - Continually ( i.e. Daily)

Hand Manipulation (ability with…)
Simple Grasping - Continually ( i.e. Daily)
Firm Grasping - Occasionally (i.e. Monthly)
Fine Manipulation - Occasionally (i.e. Monthly)
Use of Keyboards - Continually ( i.e. Daily)

Required Lifting (ability to lift…)
Up to 10 lbs - Continually ( i.e. Daily)


Pushing/Pulling (ability to push and pull…)
Up to 10 lbs - Continually ( i.e. Daily)
11 to 24 lbs - Frequently ( i.e. Weekly)

Environmental (may be exposed to…)
Infectious Diseases - Continually ( i.e. Daily)
Chemical Agents - Occasionally (i.e. Monthly)
Dust, Fumes, Gases Occasionally (i.e. Monthly)
Extremes in Temperature or Humidity - Occasionally (i.e. Monthly)
Hazardous or Moving Equipment - Occasionally (i.e. Monthly)
Unprotected Heights - Occasionally (i.e. Monthly)
Loud Noises - Occasionally (i.e. Monthly)