RN Utilization Management Coordinator

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

Scope of work

Scope of work This role includes accountability for utilization review (UR) and may include admission, concurrent, and retrospective reviews. Coordinates activities involved in the certification, recertification, and concurrent appeals process, conducting referrals for 2nd level review, as needed. Ensures timely communication with payers based on adequate and complete documentation received by the physician/provider and utilization reviews. Initiates concurrent appeals to address patient class/status downgrades or clinical denials related to medical necessity. Participates within the department to meet expected objectives and outcomes. Meets or exceeds expectations related to behavior and performance. Meets individual and departmental objectives established for Quality, Satisfaction, Growth and Financial Success. Conducts timely and accurate utilization reviews, as assigned, using organization-approved UR criteria. Works closely with physician advisors and medical staff to ensure appropriate level of care, including obtaining physician orders for patient class changes when needed. Refers cases, as defined, for 2nd level medical necessity review. Maintains daily contact with payers to obtain authorization and reauthorization information and addresses concurrent denials and/or audit requests. Provides UR and clinical documentation is adequate and complies with payer requirements. Schedules next review/follow-up reviews as required in accordance with organizational policy and procedure and payer requests. Routinely collaborates with the System Clinical Appeals and Revenue Cycle departments to expedite billing and appeals processes. Maintains and monitors assigned work queues within the Electronic Medical Record.

How Corewell Health cares for you

• Comprehensive benefits package to meet your financial, health, and work/life balance goals.


• On-demand pay program powered by Payactiv


• Discounts directory with deals on the things that matter to you, like restaurants, phone plans, spas, and more!


• Optional identity theft protection, home and auto insurance


• Traditional and Roth retirement options with service contribution and match savings Eligibility for benefits is determined by employment type and status


• Learn more here.

Qualifications Required

• Associate's Degree Associates or technical degree.


• Preferred Bachelor's Degree in nursing or related field.


• 2 years of relevant experience 2 years of experience in clinical/hospital setting.


• Required Hospital utilization review/utilization management experience.


• Preferred Clinical appeals experience.


• Preferred Registered Nurse (RN) - State of Michigan Upon Hire required

Primary Location

• SITE - 25800 Northwestern Highway - Southfield


• Department Name Utilization Management - Diversified East WB Mkt


• Employment Type Part time


• Shift Day (United States of America)


• Weekly Scheduled Hours 0.04


• Hours of Work 8


• Days Worked Monday - Friday


• Weekend Frequency N/A

Corewell Health is committed to providing a safe environment for our team members, patients, visitors, and community. We require a drug-free workplace and require team members to comply with the MMR, Varicella, Tdap, and Influenza vaccine requirement if in an on-site or hybrid workplace category. We are committed to supporting prospective team members who require reasonable accommodations to participate in the job application process, to perform the essential functions of a job, or to enjoy equal benefits and privileges of employment due to a disability, pregnancy, or sincerely held religious belief.

Corewell Health grants equal employment opportunity to all qualified persons without regard to race, color, national origin, sex, disability, age, religion, genetic information, marital status, height, weight, gender, pregnancy, sexual orientation, gender identity or expression, veteran status, or any other legally protected category.

An interconnected, collaborative culture where all are encouraged to bring their whole selves to work, is vital to the health of our organization. As a health system, we advocate for equity as we care for our patients, our communities, and each other. From workshops that develop cultural intelligence, to our inclusion resource groups for people to find community and empowerment at work, we are dedicated to ongoing resources that advance our values of diversity, equity, and inclusion in all that we do. We invite those that share in our commitment to join our team.

People are at the heart of everything we do, and the inspiration for our legacy of outstanding outcomes, innovation, strong community partnerships, philanthropy and transparency. Corewell Health is a not-for-profit health system that provides health care and coverage with an exceptional team of 60,000+ dedicated people—including more than 11,500 physicians and advanced practice providers and more than 15,000 nurses providing care and services in 22 hospitals, 300+ outpatient locations and several post-acute facilities—and Priority Health, a provider-sponsored health plan serving more than 1.2 million members. Through experience and collaboration, we are reimagining a better, more equitable model of health and wellness.