RN Utilization Review Specialist

Full-time, Monday through Friday on-site orientation for at least 6 weeks.

Scope of Work

• Provides health information and acts as a resource for nursing units for complex clinical situations to ensure appropriate use of acute care services and diagnosis-related group (DRG) management.
• Assesses appropriateness of inpatient admissions and continued stay.
• Educates medical staff and other health care professionals regarding utilization management and quality requirements.
• Makes recommendations and provides financial and utilization management (UM) information to other members of the care facilitation teams for work prioritization.
• Works closely with inpatient care facilitators and Medical Social Workers to move patients through the continuum appropriately.
• Assesses and interprets clinical information and assists in case management of complex patient population, using independent judgment, mature problem-solving skills, and guidelines for appropriateness of acute care setting upon admission and continued stay.
• Adjusts patient registration status code, as needed, to maximize reimbursement and be consistent with regulatory standards.
• Communicates with physicians, medical social workers, and other hospital personnel concerning change in level of care on the medically complex patient population; makes recommendations and discusses alternatives.
• Provides financial/DRG, UM, and health information to other facilitation team members for work prioritization.
• Communicates and collaborates with physicians and members of the team to ensure continuity and coordination of services.
• Documents instances where services were delayed, inappropriate, refused, complicated, etc., for resource management functions.
• Identifies quality indicators to facilitate process improvement and physician education.

Qualifications

• Required: Associate's Degree in Nursing
• Preferred: Bachelor's Degree in Nursing
• 2 years of relevant experience in acute care, clinical nursing (preferably multiple clinical settings), or related experience
• Required: Registered Nurse (RN) - State of Michigan license

Benefits

• Comprehensive benefits package to meet financial, health, and work/life balance goals
• On-demand pay program powered by Payactiv
• Discounts directory with deals on restaurants, phone plans, spas, and more
• Optional identity theft protection, home, and auto insurance
• Traditional and Roth retirement options with service contribution and match savings

Schedule

• Full-time, day shift
• Weekly scheduled hours: 40
• Hours of work: 8:00 AM – 4:30 PM, Monday through Friday