Registered Nurse - Utilization Management

McLaren Health Care; Mount Clemens (MI); Hybrid; USD 85,000 - 105,000; Full time

Job summary

McLaren Health Care is seeking a Registered Nurse to join the Utilization Management team. The role focuses on determining appropriate patient status, ensuring medical necessity, and documenting care for insurance and government payers within an acute care hospital context.

You will collaborate with admitting physicians and care teams, conduct concurrent reviews, and support discharge planning while maintaining compliance with payer requirements and clinical guidelines.

Qualifications

• RN license is required.
• Bachelor's degree in nursing or actively pursuing with plan to obtain within five years.
• Three years of recent nursing or utilization management experience in an acute care hospital.

Responsibilities

• Perform concurrent and retrospective utilization management reviews to track, evaluate and report data.
• Collaborate with care teams to determine appropriate inpatient vs. outpatient settings based on medical necessity.
• Expedite patient discharge with ICM services; verify documentation supports level of care and payer requirements.
• Screen documentation for timeliness, completeness, and appropriateness related to medical necessity and payer rules.
• Document clinical reviews, payer authorizations, and discharge planning in the EMR and related tools.
• Facilitate peer-to-peer reviews with payers and providers as needed.
• Participate in interdisciplinary rounds to review continued stays and LOS outliers.
• Collaborate with providers to address medical necessity questions per SOPs.

Skills

Utilization management

Nursing

Clinical documentation

Education

RN licensure

Bachelor's in Nursing

Tools

EMR (Electronic Medical Record)

Veracity

Optum

InterQual

Milliman

Job description

The McLaren system includes 12 hospitals across the state, ambulatory surgery centers, imaging centers, a 730-member employed primary and specialty care physician network, commercial and Medicaid HMOs covering more than 242,000 Michigan lives, home health, infusion and hospice providers, pharmacy services, a clinical laboratory network, and a wholly owned medical malpractice insurance company. McLaren operates Michigan’s largest network of cancer centers and providers, anchored by the Karmanos Cancer Institute, a National Cancer Institute-designated comprehensive cancer center. McLaren has 20,000 full-, part-time and contracted employees and more than 93,000 network providers throughout Michigan.

Department:Utilization Management-Remote but occasional in person

Scheduled Bi-Weekly Hours: 80

Daily Work Times:8am to 4pm

Position Summary:

Responsible for determining the appropriate patient status based on the regulatory and reimbursement requirements of various commercial and government payers in collaboration with the admitting/attending physician. Partners with the health care team to ensure hospital admissions are based on medical necessity and documentation is sufficient to support the level of care being billed. Conducts concurrent reviews to ensure criteria for patient status and continued stay are met and documented. Along with other health care team members, monitors the use of hospital resources and identifies delays. Reports delays to leadership for resolution.

Essential Functions and Responsibilities as Assigned:

• 1. Performs a variety of concurrent and retrospective utilization management-related reviews and functions to ensure that appropriate data are tracked, evaluated, and reported.
• 2. Collaborates with the health care team to determine the appropriate hospital setting (inpatient vs. outpatient) based on medical necessity. Actively seeks additional clinical documentation from the physician to optimize hospital reimbursement when appropriate.
• 3. Works collaboratively with ICM service lines to expedite patient discharge.
• 4. Screens physician documentation or order entry for timeliness, appropriateness and completeness as pertains to the utilization management process including level of care, medical necessity, and third-party payer requirement.
• 5. Documents in the electronic medical record (EMR): clinical reviews (medical necessity), payer authorizations, avoidable days, readmission risks, continued stay reviews and potential discharge date. Utilizes other application tools to document including Veracity, Optum, InterQual, Milliman, etc.
• 6. Facilitates peer to peer reviews with payer/providers.
• 7. Actively participates in clinical case review/rounds with the interdisciplinary team regarding continued stays review/LOS outliers,
• 8. Collaborate with providers/physician advisor when medical necessity and/or appropriateness of care is questioned, in accordance with established SOP procedures.
• 9. Maintains current knowledge of hospital utilization review processes and participates in the resolution of retrospective reimbursement issues including appeals, PACER authorization, third party payer certification, and denied cases.
• 10. Assists with monitoring the effectiveness/outcomes of the utilization management program, identifying and applying appropriate metrics, evaluating the data, reporting results to various audiences, and designing and implementing process improvement projects as needed.
• 11. Assists with orientation, training, and competency development for appropriate staff and colleagues on an ongoing basis.
• 12. Performs other related duties as required and directed.

Qualifications:

Required

• State licensure as a registered nurse (RN)
• Bachelor’s degree in nursing from accredited educational institution, or actively pursuing degree and to be obtained within five years of accepting position.
• Three years of recent nursing or utilization management experience with an acute care hospital

Preferred

• Experience in utilization management/case management, critical care, clinical documentation, or patient outcomes/quality management.
• Certification in Case Management Certification (ACM or CCM)
• Basic Life Support (BLS) certification as a Healthcare Provider by the American Heart Association, American Red Cross or equivalent through the Military Training Network (MTN)

Additional Information

• Schedule: Full-time
• Requisition ID: 26010545
• Daily Work Times: 8am to 4pm
• On Call: No

McLaren Health Care is an Equal Opportunity Employer. Qualified applicants will receive consideration for employment without regard to race, color, religion, sexual orientation, gender identification, age, sex, marital status, national origin, disability, genetic information, height or weight, protected veteran or other classification protected by law.