Registered Nurse Utilization Review

Employment Type

Part time Shift

Day Shift

Position purpose

• The Utilization Review Specialist is a Registered Nurse that is responsible for facilitating collection of patient clinical information and application of clinical criteria considering clinical, age specific, developmental, cultural and spiritual needs. Facilitates utilization management documentation and appropriate communication with external agencies. Demonstrates area designated competencies.
• Contingent position for weekday and weekend coverage. Will be scheduled two shifts every other weekend with a holiday commitment approximately once every 18 months.
• Eight-hour shifts with flexible start times (start generally between 6 a.m. and 9 a.m.). Additional hours available.

Miniumum qualifications

·

Education

Graduation from accredited nursing program (Effective January 1, 2013, all new hires must have a BSN degree or must agree in writing to obtain their BSN within five (5) years from date of hire.) ·

Experience

Two to three years related experience and clinically relevant knowledge regarding patient population. ·

Licensure

Current Registered Nurse license in the State of Michigan (RN).

What you will do

• Completes submission of utilization review documentation for concurrent and retrospective patients within established timelines. Ensure authorizations are obtained and communicated to ePFS teams in a timely manner.
• Identifies and resolves errors related to patient demographic and insurance information. Coordinates with Revenue Cycle departments such as Insurance Clearance as needed.
• Submits utilization review documentation for concurrent and retrospective Commercial and Managed Medicare and Medicaid payer reviews. Documents in the electronic care management module the date the clinical reviews were sent as well as authorizations obtained.
• Communicates appropriately with the case managers and physician advisors.
• Coordinates the peer-to-peer concurrent appeal process by timely identification of concurrent or potential concurrent denials.
• Communicates with the physician advisor, coordinates telephone appointments with payer Medical Directors, and provides electronic documentation of the outcomes.
• Ensures minimal medical necessity denials due to lack of clinical review information sent to the payer.
• Demonstrates excellent customer service skills with payer representatives.
• Maintains positive and collaborative relationships with members of the following departments: Care Management Department, Physician Advisors, ePFS, Patient Access, Health Information Management, Insurance Clearance, Patient Accounting to facilitate the timely and accurate completion of utilization management functions pertaining to prompt remuneration.
• Identify process improvement opportunities as appropriate. Accurately and completely documents pertinent assessments, interventions, transitions, and outcomes for patients in accordance with documentation standards, policies, procedures and/or guidelines.

Our Commitment Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.