Registered Nurse - Utilization Review
About the Department
Join the Health Alliance Plan (HAP) team, a mission-driven health plan serving members across Michigan. HAP combines healthcare expertise with a commitment to improving outcomes through innovative coverage, care management, and wellness programs. As part of Henry Ford Health, HAP offers opportunities to shape the future of health and insurance services, ensuring members receive high-quality, cost-effective care in the most appropriate settings.
Role Overview
As a Utilization Review (UR) Nurse, you will ensure services meet members' health needs by identifying, assessing, planning, coordinating, monitoring, and evaluating healthcare services and outcomes. You will collaborate with the patient care team to promote high-quality care, reduce length of stay, and ensure efficient resource utilization. Your work will directly impact the delivery of care and the appropriate reimbursement of services, including discharge planning and aftercare support.
Qualifications
What You Will Need
- Nursing Diploma or equivalent; Bachelor of Science in Nursing degree preferred.
- Four (4) years of hospital clinical experience in medical, surgical, orthopedic, neuro-surgery, or pediatric nursing.
- Demonstrated knowledge of pathophysiology with application of critical thinking skills.
- Current, valid Michigan license to practice as a Registered Nurse without conditions, limitations, or restrictions.
- Knowledge of ICD-9/ICD-10 and CPT coding, medical necessity criteria, and medical terminology.
- Excellent verbal and written communication skills, including telephone etiquette.
- Proficiency in Microsoft Office Suite and typing skills.
Preferred Qualifications
- Two (2) years of Utilization Management and/or Hospital discharge planning in the acute care setting within the past four (4) years.
- Knowledge of Medicare, Medicaid, and NCQA guidelines and use of the CMS website for research.