RN Utilization Management: Inpatient Care Optimizer

McLaren Health Care; Lapeer (MI); On-site; USD 75,000 - 95,000; Full time

Job summary

McLaren Health Care in Michigan seeks an experienced Utilization Management RN to ensure medical necessity and appropriate patient status across inpatient and outpatient settings. You will review clinical data, coordinate with physicians, and drive reimbursement through accurate documentation and timely authorizations.

Responsibilities include conducting concurrent and retrospective reviews, collaborating with care teams, and supporting process improvements while staying current with payer

Qualifications

• Must hold RN licensure and a Bachelor's in Nursing, or be pursuing degree within five years.
• At least 3 years of recent nursing or utilization management experience in an acute care hospital.
• Experience in utilization management/case management, clinical documentation, or patient outcomes/quality management.
• Case Management Certification (ACM/CCM) preferred.
• Basic Life Support (BLS) certification preferred.

Responsibilities

• Perform concurrent and retrospective utilization reviews to ensure data is tracked, evaluated, and reported.
• Collaborate to determine inpatient vs outpatient status based on medical necessity.
• Work with ICM service lines to expedite patient discharge.
• Screen documentation for timeliness, appropriateness and completeness regarding level of care and payer needs.
• Document in EMR: medical necessity, payer authorizations, avoidable days, readmission risks, discharge date.
• Facilitate peer-to-peer reviews with payers/providers.
• Participate in clinical case reviews with the interdisciplinary team on continued stays.
• Collaborate with providers when medical necessity is questioned per SOP.
• Maintain knowledge of utilization review processes and resolve retrospective issues including appeals.
• Monitor UM program effectiveness; report metrics and drive improvements.
• Assist with orientation, training and competency development.
• Perform other related duties as required.

Skills

Utilization management

Case management

Clinical documentation

Quality management

Education

Bachelor's degree in nursing

Job description

McLaren Health Care in Michigan seeks an experienced Utilization Management RN to ensure medical necessity and appropriate patient status across inpatient and outpatient settings. You will review clinical data, coordinate with physicians, and drive reimbursement through accurate documentation and timely authorizations.

Responsibilities include conducting concurrent and retrospective reviews, collaborating with care teams, and supporting process improvements while staying current with payer