RN Utilization Management: Inpatient Care Optimizer

McLaren Health Care; Lansing (MI); On-site; USD 85,000 - 110,000; Full time

Job summary

McLaren Health Care is seeking a qualified RN to lead Utilization Management, determining patient status and ensuring medical necessity for hospital admissions. You will work with the admitting physician and care team to optimize documentation for payer requirements.

The role includes concurrent reviews, discharge coordination with ICM service lines, and EMR documentation using Veracity, Optum, InterQual, Milliman tools, supporting ongoing reimbursement process improvements.

Qualifications

• Active RN license in the state of Michigan or equivalent.
• Bachelor’s degree in nursing or enrolled and expected within five years of hire.
• Three years of recent nursing or utilization management experience in an acute care hospital.

Responsibilities

• Perform concurrent and retrospective utilization management reviews to ensure appropriate data is tracked and reported.
• Collaborate with the care team to determine inpatient vs. outpatient settings based on medical necessity.
• Expedite patient discharge with ICM service lines and obtain additional clinical documentation when needed.
• Screen documentation for timeliness, appropriateness, and completeness per utilization management standards.
• Document clinical reviews, payer authorizations, avoidable days, and discharge planning in the EMR using the specified tools.
• Facilitate peer-to-peer reviews with payers and providers.
• Participate in interdisciplinary rounds to review continued stays and LOS outliers.
• Maintain knowledge of hospital utilization review processes and assist with appeals and denials as needed.
• Contribute to monitoring program effectiveness and support process improvement projects.

Skills

Utilization management

Clinical documentation

Interdisciplinary collaboration

Education

RN license

BSN preferred

Tools

Veracity

Optum

InterQual

Milliman

Job description

McLaren Health Care is seeking a qualified RN to lead Utilization Management, determining patient status and ensuring medical necessity for hospital admissions. You will work with the admitting physician and care team to optimize documentation for payer requirements.

The role includes concurrent reviews, discharge coordination with ICM service lines, and EMR documentation using Veracity, Optum, InterQual, Milliman tools, supporting ongoing reimbursement process improvements.