Utilization Review Nurse-Utilization Management

Utilization Review Nurse

Location: METROHEALTH MEDICAL CENTER

Biweekly

Hours:

80.00

Shift: Days;
Rotating Weekends and Holidays

Responsible for supporting the physician and interdisciplinary team in the provision of patient care by ensuring the appropriate level of care at the point of entry. The utilization review nurse will work on defined patient populations and is responsible for an initial clinical review at the point of patient entry to the inpatient care setting, including observation status. The nurse collaborates with other interdisciplinary team members to develop and participate in a systematic approach to denial management, reducing organizational exposure to revenue loss.

Actively participates in the denial management process to improve reimbursement by optimizing revenue recovery due to inappropriate level of care, failure to meet medical necessity, and/or severity of illness. Upholds the mission, vision, values, and customer service standards of The Metro Health System.

Provide clinical review and decision support at the point of entry for inpatient and observation status patients.

Collaborate with interdisciplinary team members to develop systematic denial management processes.

Analyze case data and documentation to determine appropriateness of care levels and medical necessity.

Participate in denial management activities to improve reimbursement and reduce revenue loss.

Uphold the mission, vision, values, and customer service standards of The Metro Health System.

• Required:
  
  Bachelor’s degree in Nursing (applies to placements after 1/1/2017).
• Current Registered Nurse license in the State of Ohio.
• Minimum of five years clinical experience.
• Able to work independently and as a member of an interdisciplinary team.
• Knowledge and experience with medical necessity criteria for inpatient admission and observation placement.
• Knowledge and experience of denials based on the absence of documented medical necessity or failure to meet severity of illness and intensity of service criteria.
• Knowledge of internal criteria set and Milliman Health Management Guidelines.
• Excellent interpersonal communication and negotiation skills.
• Strong analytical, data management, and PC skills.
• Current working knowledge of utilization management, case‑management, performance improvement, and managed care reimbursement.
• Strong organizational and time‑management skills.
• Preferred:
  Two years of experience with case management, utilization review.

Physical Demands: May need to move around intermittently during the day, including sitting, standing, stooping, bending, and ambulating. May need to remain still for extended periods, including sitting and standing. Ability to communicate in face‑to‑face, phone, email, and other communications. Ability to read job‑related documents. Ability to use computer.

Mid‑Senior level

Full‑time

Health Care Provider