RN Registered Nurse Utilization Review

Trinity Health; Ann Arbor (MI); On-site; USD 39,000 - 58,000; Part time

Job summary

Trinity Health in Ann Arbor, MI seeks a part-time Utilization Review Specialist who is a registered nurse. You will facilitate collection of patient information, apply clinical criteria, and communicate with external agencies. Weekend coverage is required on a rotating basis with occasional holidays, and shifts start between 6 a.m.

and 9 a.m. The role requires an accredited nursing degree with a BSN within five years, 2–3 years of related experience, and current Michigan RN licensure.

Qualifications

• Graduation from accredited nursing program; BSN required within 5 years.
• Two to three years related nursing experience with clinical knowledge.
• Current Registered Nurse license in Michigan (RN).

Responsibilities

• Completes submission of utilization review documentation within established timelines.
• Identifies and resolves errors in patient demographics and insurance information.
• Submits utilization review documentation for payer reviews and documents outcomes.
• Communicates with case managers, physician advisors, and payer Medical Directors.
• Coordinates peer-to-peer concurrent appeal process and timely denials identification.
• Maintains positive working relationships with Care Management and Revenue Cycle teams.
• Documents assessments, interventions, and outcomes per standards and guidelines.

Skills

Communication

Documentation

Care coordination

Collaboration

Education

BSN within 5 years

RN license (MI)

Job description

Employment Type: Part time Shift: Day Shift Description:

POSITION PURPOSE

• The Utilization Review Specialist is a Registered Nurse that is responsible for facilitating collection of patient clinical information and application of clinical criteria considering clinical, age specific, developmental, cultural and spiritual needs. Facilitates utilization management documentation and appropriate communication with external agencies. Demonstrates area designated competencies.
• Contingent position for weekday and weekend coverage. Will be scheduled two shifts every other weekend with a holiday commitment approximately once every 18 months.
• Eight-hour shifts with flexible start times (start generally between 6 a.m. and 9 a.m.). Additional hours available.

MINIUMUM QUALIFICATIONS

• Education: Graduation from accredited nursing program (Effective January 1, 2013, all new hires must have a BSN degree or must agree in writing to obtain their BSN within five (5) years from date of hire.)
• Experience: Two to three years related experience and clinically relevant knowledge regarding patient population.
• Licensure: Current Registered Nurse license in the State of Michigan (RN).

WHAT YOU WILL DO

• Completes submission of utilization review documentation for concurrent and retrospective patients within established timelines. Ensure authorizations are obtained and communicated to ePFS teams in a timely manner.
• Identifies and resolves errors related to patient demographic and insurance information. Coordinates with Revenue Cycle departments such as Insurance Clearance as needed.
• Submits utilization review documentation for concurrent and retrospective Commercial and Managed Medicare and Medicaid payer reviews. Documents in the electronic care management module the date the clinical reviews were sent as well as authorizations obtained.
• Communicates appropriately with the case managers and physician advisors.
• Coordinates the peer-to-peer concurrent appeal process by timely identification of concurrent or potential concurrent denials.
• Communicates with the physician advisor, coordinates telephone appointments with payer Medical Directors, and provides electronic documentation of the outcomes.
• Ensures minimal medical necessity denials due to lack of clinical review information sent to the payer.
• Demonstrates excellent customer service skills with payer representatives.
• Maintains positive and collaborative relationships with members of the following departments: Care Management Department, Physician Advisors, ePFS, Patient Access, Health Information Management, Insurance Clearance, Patient Accounting to facilitate the timely and accurate completion of utilization management functions pertaining to prompt remuneration.
• Identify process improvement opportunities as appropriate. Accurately and completely documents pertinent assessments, interventions, transitions, and outcomes for patients in accordance with documentation standards, policies, procedures and/or guidelines.

OUR COMMITMENT

Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care.

We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.

TRINITY HEALTH

Trinity Health is one of the largest not-for-profit, faith-based health care systems in the nation. Together, we’re 121,000 colleagues and nearly 36,500 physicians and clinicians caring for diverse communities across 27 states. Nationally recognized for care and experience, our system includes 101 hospitals, 126 continuing care locations, the second largest PACE program in the country, 136 urgent care locations, and many other health and well-being services. Based in Livonia, Michigan, in fiscal year 2023, we invested $1.5 billion in our communities through charity care and other community benefit programs.

For more information, visit http://www.trinity-health.org. You can also follow Trinity Health on LinkedIn.