RN Utilization & Appeals Specialist

Spectrum Health; Southfield (MI); On-site; USD 42,000 - 60,000; Part time

Benefits offered by this job

Comprehensive benefits package

On-demand pay (Payactiv)

Discounts directory with deals

Identity theft protection

Traditional and Roth retirement with 2

Job summary

Corewell Health is seeking a part-time Utilization Management professional in Southfield, MI, to oversee utilization reviews, coordinate certifications, and communicate with payers for authorizations. This role requires UR experience and RN licensure in Michigan.

Responsibilities include referrals for 2nd level reviews, collaboration with Clinical Appeals and Revenue Cycle, and maintaining EMR work queues to ensure timely reviews and compliant documentation.

Qualifications

• Associate's degree required; RN preferred for nursing/hospital background.
• Bachelor's degree in nursing or related field preferred.
• Minimum 2 years of clinical/hospital UR experience required; nursing experience beneficial.

Responsibilities

• Perform utilization reviews using organization-approved UR criteria.
• Coordinate certification, recertification, and concurrent reviews and appeals.
• Maintain timely communications with payers for authorizations and reauthorizations.
• Refer cases for 2nd level review as needed.
• Collaborate with Clinical Appeals and Revenue Cycle to expedite billing and appeals.
• Maintain and monitor UR work queues within the EMR.

Skills

Utilization review

Clinical documentation

Payer communication

Education

Associate's Degree

Bachelor's degree in nursing

RN license Michigan

Tools

Electronic Medical Record (EMR)

Job description

Corewell Health is seeking a part-time Utilization Management professional in Southfield, MI, to oversee utilization reviews, coordinate certifications, and communicate with payers for authorizations. This role requires UR experience and RN licensure in Michigan.

Responsibilities include referrals for 2nd level reviews, collaboration with Clinical Appeals and Revenue Cycle, and maintaining EMR work queues to ensure timely reviews and compliant documentation.