Clinical Appeals Reviewer- Utilization Management

MetroHealth; Cleveland, Northern (OH, KY); Hybrid; USD 80,000 - 100,000; Full time

Job summary

MetroHealth Medical Center in Cleveland, OH is seeking an experienced RN for a utilization management role. You will advocate for patients and ensure insurance coverage of necessary services, reviewing clinical criteria and medical records to support appropriate care and appeals.

The position requires a Bachelor's in Nursing, Ohio RN license, and at least 5 years of clinical experience, with knowledge of UM guidelines and denial management.

Qualifications

• Bachelor's degree in nursing and Ohio RN license.
• Minimum of 5 years of clinical experience.
• Knowledge of medical necessity criteria and utilization management.
• Experience with denial management and Milliman guidelines.
• Strong communication and negotiation abilities.
• Ability to work independently and with cross-disciplinary teams.
• Experience with data analysis and PC skills.

Responsibilities

• Advocates for patients and ensures services are covered by insurance.
• Reviews clinical criteria to support care inquiries regarding appropriateness.
• Analyzes medical records and reviews insurance policies.
• Consults with healthcare providers to gather information for appeals.
• Identifies evidence-based and cost-effective care alternatives.
• Upholds the system's mission, 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

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.