Clinical Appeals Reviewer- Utilization Management

The MetroHealth System (Cleveland, OH); Cleveland (OH); On-site; USD 70,000 - 85,000; Full time

Job summary

The MetroHealth System in Cleveland, OH seeks an experienced nurse to advocate for patients and ensure coverage of needed care. You will review clinical criteria, analyze records, and coordinate with providers to support appeals when appropriate.

As a key member of the utilization management team, you will educate providers on evidence‑based and cost‑effective alternatives while upholding our mission and standards of patient service across the system.

Qualifications

• Bachelor’s degree in nursing.
• Current Ohio RN license.
• Minimum 5 years clinical experience.
• Knowledge of medical necessity criteria for inpatient admission and observation.
• Familiarity with Milliman Health Management Guidelines.
• Experience with utilization management and managed care reimbursement preferred.
• Excellent interpersonal communication, critical thinking and negotiation skills.
• Strong analytical and data management skills; proficient PC skills.

Responsibilities

• Advocate for the patient and ensure services are covered by insurance.
• Review clinical criteria to support patient care inquiries regarding appropriateness of treatments.
• Analyze medical records and consult with healthcare providers for appeals information.
• Participate in efforts to educate providers on evidence-based and cost-effective alternatives.
• Uphold the mission, vision, values and customer service standards.

Skills

Interpersonal communication

Critical thinking

Negotiation skills

Analytical skills

Data management

PC skills

Education

Bachelor's degree in nursing

Ohio RN license

Tools

Milliman Health Management Guidelines

Job description

Location: METROHEALTH MEDICAL CENTER
Biweekly Hours: 80.00
Shift: 7a-330p

The MetroHealth System is redefining health care by going beyond medical treatment to improve the foundations of community health and well-being: affordable housing, a cleaner environment, economic opportunity and access to fresh food, convenient transportation, legal help and other services. The system strives to become as good at preventing disease as it is at treating it. Founded in 1837, Cuyahoga County’s safety-net health system operates four hospitals, four emergency departments and more than 20 health centers.

Summary

Advocates for the patient and ensures that appropriate and necessary healthcare services are covered by insurance. Reviews clinical criteria to support patient care inquiries regarding the appropriateness of requested treatments, procedures, and therapies for patients of The MetroHealth System (MHS). Analyzes medical records, reviews insurance policies, and consults with healthcare providers to gather the necessary information required for the appeal process when appropriate. Participates in on-going efforts to identify and educate providers regarding evidence-based and cost-effective alternatives for care delivery. Upholds the mission, vision, values and customer service standards of the MHS.

Qualifications

Bachelor’s degree in nursing. Current Registered Nurse License State of Ohio. Minimum of 5 years clinical experience. 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. Current working knowledge of, utilization management, case-management, performance improvement, and managed care reimbursement. Excellent interpersonal communication, critical thinking and negotiation skills. Strong analytical, data management, and PC skills. Ability to work independently and as a member of an interdisciplinary team. Ability to interact effectively with a wide range of cultural, ethnic, racial, and socioeconomic backgrounds. Preferred: 3 years of experience with a Utilization Management focus. Working knowledge of current utilization management, revenue cycle, performance improvement, and / or managed care reimbursement practices. 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.