Appeals Reviewer, Utilization Management (RN)

The MetroHealth System; Cleveland (OH); On-site; USD 85,000 - 110,000; Full time

Job summary

The MetroHealth System is seeking a Clinical Appeals Reviewer in Utilization Management. This on-site role supports insurance coverage decisions by reviewing medical necessity and medical records to determine appropriateness of requested treatments for MetroHealth System patients.

Ideal candidates hold an Ohio RN license, have 5+ years of clinical experience, and are skilled in evidence-based utilization management and payer denials processes.

Qualifications

• Bachelor’s degree in nursing is required.
• RN license in the state of Ohio is required.
• Minimum of 5 years of clinical experience.
• Knowledge of medical necessity criteria for inpatient admission and observation placement.
• Knowledge of denials based on lack of medical necessity or severity of illness criteria.
• Familiarity with utilization management processes and managed care reimbursement.

Responsibilities

• Advocate for patients and ensure appropriate/necessary services are covered by insurance.
• Review clinical criteria to support patient care inquiries for treatments, procedures, and therapies.
• Analyze medical records, review policies, and consult with providers to gather information for the appeal process.
• Educate providers about evidence-based and cost-effective alternatives.
• Uphold MetroHealth's mission, vision, values, and customer service standards.

Skills

Interpersonal communication

Critical thinking

Negotiation skills

Analytical

Data management

PC skills

Education

Bachelor’s degree in nursing.

Job description

The MetroHealth System is seeking a Clinical Appeals Reviewer in Utilization Management. This on-site role supports insurance coverage decisions by reviewing medical necessity and medical records to determine appropriateness of requested treatments for MetroHealth System patients.

Ideal candidates hold an Ohio RN license, have 5+ years of clinical experience, and are skilled in evidence-based utilization management and payer denials processes.