All the benefits and perks you need for you and your family:
Paid Days Off
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 that together we are even better.
Located in the historic town of Zephyrhills with easy access to Tampa, Wesley Chapel, and Lakeland
113 bed recently renovated skilled nursing facility
In close proximity to Adventhealth Zephyrhills
120-bed facility in historic Zephyrhills, FL
Gorgeous lakeside location with view of a beautiful lake, activities in the park; including ducks, wildlife, and domestic pets out on strolls with their owners
Majestic Oaks and many types of trees create a restful and peaceful, green view.
Two exceptional memory care support units
Joint Commission accredited
Wonderful, friendly, family-oriented atmosphere, with a great amount of staff longevity who contributes to that family atmosphere
The role you’ll contribute:
Accurately interprets benefits and managed care products to collaborate with the healthcare providers (facility), member and payer to promote quality member outcomes, optimize member benefits, promote effective use of resources. Works independently and with the interdisciplinary team (nursing, therapy, social services, BOM and billing) to coordinate utilization of the managed care (Medicare Advantage, Commercial, alternative payment plans) from post-admit through the end of stay. This person is the primary facility liaison from admission to post-admission for the managed care case manager. Monitors and evaluates data, fiscal outcomes and other relevant information to develop and implement strategies for improvement. Ensures compliance with all regulatory standards including Federal, State, Local with review requirements for Managed Contracts related to admission and continued stay approvals.
The value you’ll bring to the team:
· Knowledge of federal, state, and local government regulations and legislation and their impact on health care service.
· Use professional clinical knowledge to analyze and review the patient profile for medical necessity guidelines and accuracy of achieved level of care provided to facility the utilization review process.
· Research, review and prepare medical information to present and collaborate with the payer objectively regarding continued stay reviews.
· Ensures patient’s access to medically necessary, high-quality healthcare in a cost-effective setting according to contract
· Field all calls from the plans case manager to the facility as the point of contact representative for the facility.
· Communicate with physician, MDS, nursing, therapy and social services weekly regarding continued stay
· Attend facility weekly UR meeting either remotely or in person as indicated.
· Collaborates timely with case managers in peer-to-peer discussions to increase/continued lengths of stay for skilled patients, re-evaluate admitting diagnosis for skilled services, and notify insurance if need for change, validation of higher reimbursement levels.
· Develops collaborative relationships with plan case manager, patient/family, facility to facilitate efficient movement through the continuum of care.
· Identify outliers in clinical presentation to justify supplemental reimbursement based on managed care contract specific guidelines and obtain documentation including letter of agreement.
· Knowledge of the Medicare Skilled coverage criteria and documentation requirements.
· Review clinical status of resident and provide clinical information to the managed care organization.
· Assist with month-end billing by completing level of care and exclusion accuracy audits that are preventing month-end close as soon as feasible.
· Dispute disagreements with the payer’s case manager as a representative of the facility in regard to level of changes, concurrent disputes and potential discharges.
· Communicates appropriately and clearly to co-workers, billing managers, medical records staff, clinical managers, administrator, managed care organizations and physicians. .
· Demonstrates an ability to be flexible when situations require and function effectively and in a collegial manner in stressful situations.
· Identifies the needs of the resident and communicates those needs to the facility discharge planner prior to the resident’s discharge.
· Follows facility guidelines on escalation processes and refer cases appropriately to the internal or external stakeholder.
· Provides staff teaching as required.
· Other duties as assigned.
The expertise and experiences you’ll need to succeed:
Graduate of a qualified health-care related program: COTA, PTA, LPN, RN
3-5 years of clinical experience in a health care setting, preferably long-term care and skilled nursing facility
Managed care and utilization management experience required
Working knowledge of utilization management, case management, post-acute and long-term care, Patient Driven Payment Method Reimbursement model
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.