RN Utilization Rvw Spclst - Utilization Management

Responsibilities

• Review inpatient and observation admissions to ensure correct assignment of Admit status.
• Communicate concurrently and resolve medical necessity discrepancies with physicians and other hospital leadership as needed.
• Complete clinical review on all assigned patients and communicate these reviews to payers.
• Identify potential or actual denials for admission or ongoing stay both during the patient’s hospital stay and post discharge.
• Review and decide the validity of medical necessity payer denials.
• Submit payer denial appeals.
• Participate in design of work flows and procedures to reduce incidence of denials.

Requirements

• Registered professional nurse with education, knowledge, and experience.
• BSN required.
• Current unrestricted Ohio RN licensure.
• Preferred qualifications include 5 years clinical experience with 2 years case management, Case Management certification, works independently, familiarity with MCG Care guidelines, ability to adapt quickly to changing priorities and regulations, and experience with computers and Microsoft applications and EPIC software.

Qualifications

Registered professional nurse with education, knowledge, and experience.

Skills

Communication skills, critical thinking, attention to detail, computer proficiency, and familiarity with healthcare regulations and guidelines.

Benefits

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

Pay

Varied based on experience and qualifications.

Schedule

Varied shifts to accommodate hospital needs.

Overview

Kettering Health is a not-for-profit system of 14 medical centers and more than 120 outpatient facilities serving southwest Ohio. Our mission is to live God’s love by promoting and restoring health, and we are committed to helping individuals be their best. Safety is our top priority, and we provide an integrated system of healthcare experts committed to providing exceptional care.