Baptist Health is the region's largest not-for-profit healthcare organization, with 12 hospitals, over 29,000 employees, 4,500 physicians and 200 outpatient centers, urgent care facilities and physician practices across Miami-Dade, Monroe, Broward and Palm Beach counties. With internationally renowned centers of excellence in cancer, cardiovascular care, orthopedics and sports medicine, and neurosciences, Baptist Health is supported by philanthropy and driven by its faith-based mission of medical excellence. For 26 years, we've been named one of Fortune's 100 Best Companies to Work For, and in the 2025-2026 U.S. News & World Report Best Hospital Rankings, Baptist Health was the most awarded healthcare system in South Florida, earning 63 high-performing honors.
What truly sets us apart is our people. At Baptist Health, we create personal connections with our colleagues that go beyond the workplace, and we form meaningful relationships with patients and their families that extend beyond delivering care. Many of us have walked in our patients' shoes ourselves and that shared experience fuels our commitment to compassion and quality. Our culture is rooted in purpose, and every team member plays a part in making a positive impact – because when it comes to caring for people, we're all in.
At Baptist Health, we're committed to supporting our employees at every stage of their journey, both personally and professionally. Our approach is rooted in a "grow our own" philosophy, designed to help our team members build meaningful, long-term careers with us, supported by benefits that make a real difference, including:
- Career growth and development opportunities, with clear pathways and ongoing support
- Comprehensive health and wellness resources that go beyond traditional benefits
- A wellness program that can help employees eliminate their medical plan deductible, reducing out-of-pocket healthcare costs
- Tuition reimbursement to support continued learning and advancement
- And so much more
Together, these benefits and others reflect our commitment to caring for our people, so they can build fulfilling careers with us while making a meaningful impact every day.
Description:
This position conducts concurrent retrospective reviews for clinical, financial, resource utilization. Coordinates with Healthcare team to achieve optimal efficient outcomes, decreasing length of stay (LOS) and avoiding delays/denied days. Helps drive change by identifying areas of performance improvement (e.g., day to day workflow, education, process improvements, patient satisfaction). Is accountable for a designated caseload and provides intervention, coordination to decrease avoidable delays/denial of payment resources. Specific functions include: Facilitation of pre-certification and payer authorization processes, Screens pre-admission and admission process by using established criteria for all points of entry, Facilitates communication between payers, review agencies and health care team. Identifies delays in treatment or appropriate utilization and serves as a resource, application of process improvement methodologies in evaluating outcomes of care. Coordinating communication with physicians and identifies opportunities for expedited appeals and collaborates to resolve payer issues. Ensures/Maintains effective communication with Revenue Cycle Departments Access Management and other members of the healthcare team to ensure timely communication to payers.Estimated salary range for this position is $80516.80 - $107087.34 / year depending on experience.
Qualifications:
Degrees:
Licenses & Certifications:
- MCG Care Guidelines Specialist.
- ANCC Nursing Case Management.
- ANCC Nurse Executive, Advanced Certification.
- ANCC Nurse Executive - Board Certified.
- AAMCN Utilization Review Professionals.
- McKesson Certified Professional in Utilization Management.
- NAHQ Certified Professional in Healthcare Quality.
- NACCM Care Manager Certified.
- ACMA Case Management Administrator Certification.
- ACMA ACM Certification.
- Registered Nurse.
- CCMC Case Manager.
Additional Qualifications:
- RNs hired prior to 2-2012 (10/1/2017 at Bethesda or 7/1/2019 at BRRH) with an Associates Degree in Nursing are not required to have a BSN to continue their non-leadership role as an RN.
- however, they are required to complete the BSN within 3 years of job entry date.
- RN license, MCG Specialist Certification-SCG/GCR and one of the listed certifications required.
- 3 years of Nursing experience preferred with 2 years of hospital or payor utilization management experience required.
- Excellent written, interpersonal communication and negotiation skills.
- Strong critical thinking skills and the ability to perform clinical chart review abstract information efficiently.
- Strong analytical, data management and computer skills.
- Strong organizational and time management skills, as evidenced by capacity to prioritize multiple tasks and role components.
- Current working knowledge of payer and managed care reimbursement preferred.
- Ability to work independently and exercise sound judgment in interactions with the health care team and patients/families.
- Knowledgeable in local, state, and federal legislation and regulations.
- Ability to tolerate high volume production standards.
Minimum Required Experience: 3 Years
EOE, including disability/vets
