RN Case Mgr/Doc Specialist
Position Summary Promotes and facilitates effective use of outpatient hospital and clinic resources.
Responsibilities Essential Functions • Assists with developing comprehensive case management plan addressing patient/family needs.
• Audits documentation and denied claims, ensures compliance with documentation requirements, and assists in resolving medical necessity pre- and post-payment issues.
• Interacts with patients and family members, physicians, nurses, and other physician office staff, business office, pharmacy, insurance companies, and other departments to facilitate delivery of quality patient care ensuring medical necessity criteria are met.
• Audits accounts when preauthorization has been denied for outpatient services and determines process for appeal, etc.
Facilitates physician-to-physician case reviews as needed.
• Collaborates with representatives from PFS/appeals department to appropriately facilitate all appeals with Administrative Law Judge.
• Conducts audits of orders written to ensure medical necessity criteria are met.
Reviews claim denials and collaborates with physicians to establish medical necessity.
Reviews denials of off label treatments in compliance with review requirements for Managed Care contracts, governmental payers (i.e.
Medicare, Medicaid, and Champus), and departmental review policies.
Collaborates with physicians regarding medical necessity criteria and determination of pursuit of appeal.
• Develops collaborative relationships with patients/families, patient business, nursing staff/leadership, physicians, social workers, and ancillary services to facilitate optimum outcomes of outpatient case management activities.
• Collaborates with coding, PFS, revenue integrity and appeals departments to ensure medical necessity criteria are met for billable charges.
Conducts medical review of charges for coding and billing accuracy and medical appropriateness in support of payment policies of organization and individual payers.
• Conducts audit of pre-billed claims within database for medical necessity and provides additional required information to support billable charge.
Identifies inappropriate charges and works with billing/revenue integrity departments to identify root cause.
Works closely with charge analysts as a medical resource.
• Performs retroactive medical records review to determine medical necessity of services.
• Identifies trends within the outpatient departments and provides staff education for performance improvement.
• Participates in outpatient staff meetings, revenue committee meetings, case management staff meetings, and task force working to facilitate Sunrise into the outpatient practice areas.
Offers cost-containment suggestions and provides feedback as needed.
• Provides ongoing education to physicians and staff as well as referring off campus physicians regarding medical necessity criteria and reimbursement guidelines.
• Maintains reasonably regular, punctual attendance consistent with Orlando Health policies, the ADA, FMLA, and other federal, state, and local standards.
• Maintains compliance with all Orlando Health policies and procedures.
Qualifications Education/Training • For Team Members hired into this job prior to January 1, 2020:
o Completion of an accredited RN education/training program o Bachelor's degree • Effective January 1, 2020:
New Hires and Team Members moved into this job and/or transferring Depts.
must obtain a Bachelor of Science in Nursing degree (BSN) within 36 months of placement.
Licensure/Certification Maintain current RN license in the state of Florida.
Experience • Five (5) years' acute care experience, OR • Five (5) years' experience in case management, hospital discharge planning, risk management, quality assurance, and/or utilization review
Education/Training • For Team Members hired into this job prior to January 1, 2020:
Essential Functions • Assists with developing comprehensive case management plan addressing patient/family needs.
US - FL - FL - Callahan
January 18, 2025
Various Home Time and Sign-On Bonuses Available In Select Areas. • Company Driver Benefits: • Home time varies per locationOpportunities may be available with SIGN-ON BONUSES in Select Areas!Newer equipment averaging 18 MonthsConvenient Home-Base TerminalsHealth, Dental & Vision...
US - FL - FL - Graham
January 18, 2025
Various Home Time and Sign-On Bonuses Available In Select Areas. • Company Driver Benefits: • Home time varies per locationOpportunities may be available with SIGN-ON BONUSES in Select Areas!Newer equipment averaging 18 MonthsConvenient Home-Base TerminalsHealth, Dental & Vision...
US - FL - FL - Clermont
January 18, 2025
Various Home Time and Sign-On Bonuses Available In Select Areas. • Company Driver Benefits: • Home time varies per locationOpportunities may be available with SIGN-ON BONUSES in Select Areas!Newer equipment averaging 18 MonthsConvenient Home-Base TerminalsHealth, Dental & Vision...
US - FL - FL - Polk City
January 18, 2025
Various Home Time and Sign-On Bonuses Available In Select Areas. • Company Driver Benefits: • Home time varies per locationOpportunities may be available with SIGN-ON BONUSES in Select Areas!Newer equipment averaging 18 MonthsConvenient Home-Base TerminalsHealth, Dental & Vision...
US - FL - FL - Putnam Hall
January 18, 2025
Various Home Time and Sign-On Bonuses Available In Select Areas. • Company Driver Benefits: • Home time varies per locationOpportunities may be available with SIGN-ON BONUSES in Select Areas!Newer equipment averaging 18 MonthsConvenient Home-Base TerminalsHealth, Dental & Vision...
US - FL - FL - Apollo Beach
January 18, 2025
Various Home Time and Sign-On Bonuses Available In Select Areas. • Company Driver Benefits: • Home time varies per locationOpportunities may be available with SIGN-ON BONUSES in Select Areas!Newer equipment averaging 18 MonthsConvenient Home-Base TerminalsHealth, Dental & Vision...
US - FL - FL - Citra
January 18, 2025
Various Home Time and Sign-On Bonuses Available In Select Areas. • Company Driver Benefits: • Home time varies per locationOpportunities may be available with SIGN-ON BONUSES in Select Areas!Newer equipment averaging 18 MonthsConvenient Home-Base TerminalsHealth, Dental & Vision...
US - FL - FL - Gainesville
January 18, 2025
Various Home Time and Sign-On Bonuses Available In Select Areas. • Company Driver Benefits: • Home time varies per locationOpportunities may be available with SIGN-ON BONUSES in Select Areas!Newer equipment averaging 18 MonthsConvenient Home-Base TerminalsHealth, Dental & Vision...
US - FL - FL - Apalachicola
January 18, 2025
Various Home Time and Sign-On Bonuses Available In Select Areas. • Company Driver Benefits: • Home time varies per locationOpportunities may be available with SIGN-ON BONUSES in Select Areas!Newer equipment averaging 18 MonthsConvenient Home-Base TerminalsHealth, Dental & Vision...
US - FL - FL - Fort Walton Beach
January 18, 2025
Various Home Time and Sign-On Bonuses Available In Select Areas. • Company Driver Benefits: • Home time varies per locationOpportunities may be available with SIGN-ON BONUSES in Select Areas!Newer equipment averaging 18 MonthsConvenient Home-Base TerminalsHealth, Dental & Vision...
US - FL - FL - Lake Panasoffkee
January 18, 2025
Various Home Time and Sign-On Bonuses Available In Select Areas. • Company Driver Benefits: • Home time varies per locationOpportunities may be available with SIGN-ON BONUSES in Select Areas!Newer equipment averaging 18 MonthsConvenient Home-Base TerminalsHealth, Dental & Vision...
US - FL - FL - Bagdad
January 18, 2025
Various Home Time and Sign-On Bonuses Available In Select Areas. • Company Driver Benefits: • Home time varies per locationOpportunities may be available with SIGN-ON BONUSES in Select Areas!Newer equipment averaging 18 MonthsConvenient Home-Base TerminalsHealth, Dental & Vision...
US - FL - FL - Fernandina Beach
January 18, 2025
Various Home Time and Sign-On Bonuses Available In Select Areas. • Company Driver Benefits: • Home time varies per locationOpportunities may be available with SIGN-ON BONUSES in Select Areas!Newer equipment averaging 18 MonthsConvenient Home-Base TerminalsHealth, Dental & Vision...
US - FL - FL - Crestview
January 18, 2025
Various Home Time and Sign-On Bonuses Available In Select Areas. • Company Driver Benefits: • Home time varies per locationOpportunities may be available with SIGN-ON BONUSES in Select Areas!Newer equipment averaging 18 MonthsConvenient Home-Base TerminalsHealth, Dental & Vision...
US - FL - FL - Molino
January 18, 2025
Various Home Time and Sign-On Bonuses Available In Select Areas. • Company Driver Benefits: • Home time varies per locationOpportunities may be available with SIGN-ON BONUSES in Select Areas!Newer equipment averaging 18 MonthsConvenient Home-Base TerminalsHealth, Dental & Vision...
US - FL - FL - Altha
January 18, 2025
Various Home Time and Sign-On Bonuses Available In Select Areas. • Company Driver Benefits: • Home time varies per locationOpportunities may be available with SIGN-ON BONUSES in Select Areas!Newer equipment averaging 18 MonthsConvenient Home-Base TerminalsHealth, Dental & Vision...
US - FL - FL - Montverde
January 18, 2025
Various Home Time and Sign-On Bonuses Available In Select Areas. • Company Driver Benefits: • Home time varies per locationOpportunities may be available with SIGN-ON BONUSES in Select Areas!Newer equipment averaging 18 MonthsConvenient Home-Base TerminalsHealth, Dental & Vision...
US - FL - FL - Blountstown
January 18, 2025
Various Home Time and Sign-On Bonuses Available In Select Areas. • Company Driver Benefits: • Home time varies per locationOpportunities may be available with SIGN-ON BONUSES in Select Areas!Newer equipment averaging 18 MonthsConvenient Home-Base TerminalsHealth, Dental & Vision...
US - FL - FL - Hernando
January 18, 2025
Various Home Time and Sign-On Bonuses Available In Select Areas. • Company Driver Benefits: • Home time varies per locationOpportunities may be available with SIGN-ON BONUSES in Select Areas!Newer equipment averaging 18 MonthsConvenient Home-Base TerminalsHealth, Dental & Vision...
US - FL - FL - Wausau
January 18, 2025
Various Home Time and Sign-On Bonuses Available In Select Areas. • Company Driver Benefits: • Home time varies per locationOpportunities may be available with SIGN-ON BONUSES in Select Areas!Newer equipment averaging 18 MonthsConvenient Home-Base TerminalsHealth, Dental & Vision...
US - FL - FL - Sydney
January 18, 2025
Various Home Time and Sign-On Bonuses Available In Select Areas. • Company Driver Benefits: • Home time varies per locationOpportunities may be available with SIGN-ON BONUSES in Select Areas!Newer equipment averaging 18 MonthsConvenient Home-Base TerminalsHealth, Dental & Vision...
US - FL - FL - Wauchula
January 18, 2025
Various Home Time and Sign-On Bonuses Available In Select Areas. • Company Driver Benefits: • Home time varies per locationOpportunities may be available with SIGN-ON BONUSES in Select Areas!Newer equipment averaging 18 MonthsConvenient Home-Base TerminalsHealth, Dental & Vision...
US - FL - FL - Georgetown
January 18, 2025
Various Home Time and Sign-On Bonuses Available In Select Areas. • Company Driver Benefits: • Home time varies per locationOpportunities may be available with SIGN-ON BONUSES in Select Areas!Newer equipment averaging 18 MonthsConvenient Home-Base TerminalsHealth, Dental & Vision...
US - FL - FL - Lutz
January 18, 2025
Various Home Time and Sign-On Bonuses Available In Select Areas. • Company Driver Benefits: • Home time varies per locationOpportunities may be available with SIGN-ON BONUSES in Select Areas!Newer equipment averaging 18 MonthsConvenient Home-Base TerminalsHealth, Dental & Vision...
US - FL - FL - Miramar Beach
January 18, 2025
Various Home Time and Sign-On Bonuses Available In Select Areas. • Company Driver Benefits: • Home time varies per locationOpportunities may be available with SIGN-ON BONUSES in Select Areas!Newer equipment averaging 18 MonthsConvenient Home-Base TerminalsHealth, Dental & Vision...
US - FL - FL - Anthony
January 18, 2025
Various Home Time and Sign-On Bonuses Available In Select Areas. • Company Driver Benefits: • Home time varies per locationOpportunities may be available with SIGN-ON BONUSES in Select Areas!Newer equipment averaging 18 MonthsConvenient Home-Base TerminalsHealth, Dental & Vision...
US - FL - FL - Nobleton
January 18, 2025
Various Home Time and Sign-On Bonuses Available In Select Areas. • Company Driver Benefits: • Home time varies per locationOpportunities may be available with SIGN-ON BONUSES in Select Areas!Newer equipment averaging 18 MonthsConvenient Home-Base TerminalsHealth, Dental & Vision...