Career Center

RN-Utilization Management AdventHealth Gordon 

Location Address: 1035 Red Bud Road, Calhoun, GA 30701

Top Reasons To Work At AdventHealth Gordon

• Faith based organization
• Employee Referral Program
• Educational Reimbursement Plans
• Located in the foothills of the North Georgia Mountains
• Co-workers that feel like family

Work Shifts/Hours:

Full-time Night Shift  

You Will Be Responsible For:

• Monitors admissions and performs initial patient reviews within 24 hours of admission; and when warranted by length of stay, utilization review plan, and/or best practice guidelines, on a continuing basis.
• Collaborates with medical staff, nursing staff, payor, and ancillary staff to eliminate barriers to efficient delivery of care in the appropriate setting. Communicates with all parties (i.e., staff, physicians, payers, etc.) in a helpful and courteous manner while extending exemplary professionalism. Anticipates and responds to inquiries and needs in an assertive, yet courteous manner. Demonstrates positive interdepartmental communication and cooperation.
• Interacts with physicians, physician office personnel, and/or case management departments on an as-needed basis to assure resolution of pending denials, which have been referred to the physician for peer-to-peer review with the Medical Director of the insurance carrier.
• Performs pre-admission status recommendation in Emergency Department or elective procedure settings as assigned, to communicate with providers status guidance based on available information.
• Maintaining thorough knowledge of payer guidelines, familiarity with payer processes for initiating authorizations, and following through accordingly to prevent loss of reimbursement, including the management of concurrent and pre-bill denials.
• Ensuring all benefits, authorization requirements, and collection notes are obtained and clearly documented on accounts in the pursuit of timely reimbursement within established timeframes to avoid denials.

What You Will Need:

• ASN/BSN degree required
• Current GA RN license
• Minimum three years acute care clinical experience required 
• Minimum two years Utilization Management experience, or equivalent professional experience
• Strong analytical, data management, and computer skills.
• Strong organizational and time management skills, as evidenced by capacity to prioritize multiple tasks and role components.

Job Summary:

The role of the UM RN is to use clinical expertise by analyzing patient records to determine legitimacy of hospital admissions, treatment and appropriate level of care. The UM RN is responsible to document findings based on department and regulatory standards.