RN Utilization Rvw Spclst - Utilization Management

Responsibilities

• Review inpatient and observation admissions to ensure correct assignment of Admit status.
• Communicate with physicians and other hospital leadership to resolve medical necessity discrepancies.
• Complete clinical reviews on all assigned patients and communicate these reviews to payers.
• Identify potential or actual denials for admission or ongoing stay during and after the patient's hospital stay.
• Decide the validity of medical necessity payer denials and submit denial appeals.
• Participate in designing work flows and procedures to reduce incidence of denials.

Requirements

• Current unrestricted Ohio RN licensure, BSN required.
• Experience with computers required.
• 5 years clinical experience with 2 years case management experience preferred.
• Case Management certification preferred.
• Ability to work independently.
• Familiarity with MCG Care guidelines.
• Experience with Microsoft applications and EPIC software.

Qualifications

Registered professional nurse with education, knowledge and experience.

Skills

Knowledge of medical necessity and payer denials processes.

Benefits

Kettering Health offers a comprehensive benefits package including health insurance, retirement plans, and paid time off.

Pay

Compensation is commensurate with experience.

Schedule

Varied shifts available.