PRN Utilization Management RN Reviewer NE

About the role

Utilization Management (UM) Specialists perform UM activities, such as admission review, concurrent review, retrospective chart review and clinical systems review to measure clinical performance and UM issues that affect reimbursement for the patient’s hospital stay or visit. Some of the responsibilities of a Utilization Management Specialist include medical record review, providing clinical information to payers, UM data collection and reporting, concurrent denials appeals process, clinical team interaction, Physician Adviser interaction and special projects.

Responsibilities

• Recommend resource utilization.
• Prioritize and organize work to meet changing priorities.
• Utilize analytical abilities required to gather data.
• Use clinical judgment to apply predetermined criteria or use independent clinical judgment when no predetermined criteria exist to identify problems, facilitate resolution, recommend corrective action, and report results effectively.
• Use independent clinical judgment in reviewing records to determine status of patients stay, if proper procedures have been followed, seriousness of incidents and ability to identify need for and participate in focused reviews, special projects and identify opportunities for improvement.
• Make recommendations regarding appropriateness of the treatment plan for continued stay and safety of the discharge plan.
• Achieve a minimum of 85% on IRR quarterly.
• Complete utilization management for assigned patients with at least 25-30 reviews per day.
• Apply medical necessity guidelines accurately to monitor appropriateness of admission and continued stays.
• Document appropriately in UM notes to provide evidence that the UR process for the case was followed.
• Attend all staff meetings when scheduled to work.
• Other duties as assigned.

Requirements

• Graduate of an accredited school of nursing
• Current state licensure as a Registered Nurse (RN)
• Basic Life Support (BLS) certification through the American Heart Association (AHA) or American Red Cross
• Three years of equivalent full-time clinical experience as a Registered Nurse
• Knowledge of medical terminology, anatomy and physiology, diagnosis, surgical procedures, and basic disease processes
• Analytical ability to gather data, decide on conformity based on predetermined criteria, identify problems and refer for resolution
• Basic knowledge of medical records coding standards
• Awareness of licensing and accreditation standards
• Proficient with Microsoft Office
• Knowledge of billing practices, identification of billing problems, adequacy of documentation, and ability to conduct research of issue at hand, as well as formulate recommendations based on findings.
• Knowledge and experience with Care Guidelines, Medical Necessity Criteria and/or other UM criteria sets
• Ability to assess medical records and make determinations on length of stay and proper procedures in accordance with policies and procedures
• Knowledge of and ability to use multiple Hospital information systems and Department's software
• Ability to use copier, fax machine and personal computer

Qualifications

• Bachelor of science in nursing (BSN) preferred
• Case Management Certification (CCM) preferred within first year of eligibility
• Prior Utilization Management experience preferred
• Case management or ED experience preferred

Physical Requirements

• Requires walking, sitting, and/or standing for long periods of time.
• Requires constant attention to detail, reading of medical records, and meeting deadlines.
• Works in an environment where there is some discomfort due to dust, noise, temperature.

Benefits

• Health Plan Options
• Dental Care
• Vision Care
• Flexible Spending Accounts
• Life Insurance
• Short- and Long-term Disability Coverage
• Cleveland Clinic Investment Pension Plan
• The 401(k) / 403(b) Plan
• Paid Time Off (PTO)
• Caregiver discounts
• Adoption assistance
• Employee Assistance Program
• Employee Hardship Fund
• Paid maternity and parental leave