Performs utilization review functions for the department to ensure compliance with external payor requirements which may include, but may not be limited to: pre-certification requests, admission review, concurrent review, discharge readiness and retrospective review and denial and appeal management. Provides comprehensive Utilization Management services, working in conjunction with the health care team, including health plans, the Centers for Medicare and Medicaid Services (CMS), physicians, and other health care providers to promote appropriate and efficient hospital services. The Utilization Review (UR) Coordinator evaluates the appropriateness of level of care using McKesson InterQual guidelines. The UR Coordinator works under the general supervision of a Registered Nurse Manager and may receive additional guidance from a UR Team Lead Nurse, the Physician Advisor, Sr. Medical Director or a Clinical Consultant. The incumbent operates in a complex and constantly changing environment and with large number of benefit plan variables, requiring the incumbent to exercise judgment, which results in a significant impact on the cost of care. The position also complies with state and federal regulations, Shands Policy, and health plan requirements.

Age of Patients Served:
All Age Groups
Required Education:
Associate's degree.
Specific course work: Graduate of an accredited school of nursing.
New hires effective June 14, 2017, must have a BSN degree from an accredited school of nursing within three (3) years of hire or transfer into the position. New hires or transfers into in the position between August 1, 2013 and June 13, 2017 must abide with the conditions in his or her offer letter and the verbiage in the job description signed upon hire or transfer into the position. Current employees who were hired or transferred into the position prior to August 1, 2013 will be grandfathered.
Preferred Education:
Bachelor's in Nursing.
Necessary Skills:
Excellent verbal and written communication skills.
Proficient PC skills.
Working knowledge of medical terminology, anatomy and physiology, disease and pathology.
Analyze patient records and participate in interdisciplinary collaboration with professional staff.
Problem solving and good decision-making skills.
Ability to determine medical necessity, appropriateness and level of care.
Conflict resolution skills.
Excellent time management and organizational skills.
Ability to maintain a sense of professionalism at all times.
10. Ability to work independently.
11. Demonstrated teamwork and flexibility in a fast-paced, changing environment.
Required Licensure/Certifications:
Licensed to practice nursing in the state of Florida
Required Experience:
1-2 years - Utilization review experience or the equivalent combination of education and/or experience;
-AND-
3-5 years - Clinical experience in the acute care setting or the equivalent combination of education and/or experience.
Preferred Experience:
Knowledge of InterQual criteria, certification in Utilization Review or Utilization Mgmt.