RN Utilization Management Specialist

McLaren Health Care; Lansing (MI); On-site; USD 80,000 - 110,000; Full time

Job summary

McLaren Health Care in Michigan is seeking a registered nurse to fill a Utilization Management role focused on inpatient and acute care hospital settings. You will collaborate with the care team to ensure medical necessity and proper documentation for payer reviews.

Daily duties include performing UM reviews, coordinating with physicians, expediting discharge, and documenting in EMR. A BSN and 3 years UM experience are preferred, with CCM/ ACM and BLS desirable.

Qualifications

• State-licensed RN with BSN or pursuing degree within five years.
• Three years of acute care nursing or utilization management experience.
• Preferred: CCM/ACM certification and BLS.

Responsibilities

• Perform concurrent and retrospective UM reviews to track data.
• Determine inpatient vs. outpatient status based on medical necessity.
• Collaborate with ICM to expedite discharge.
• Screen documentation for timeliness, appropriateness, and completeness.
• Document clinical reviews, authorizations, and discharge dates in EMR.
• Participate in peer-to-peer reviews with payers/providers.
• Engage in clinical rounds regarding continued stays and LOS optimization.
• Assist in program measurement and process-improvement initiatives.
• Provide orientation and competency development for staff.

Skills

Utilization management

Nursing

Interdisciplinary collaboration

EMR documentation

Education

Bachelor’s degree in nursing

RN licensure (state)

CCM/ ACM certification

BLS certification

Tools

Veracity

Optum

InterQual

Milliman

Job description

McLaren Health Care in Michigan is seeking a registered nurse to fill a Utilization Management role focused on inpatient and acute care hospital settings. You will collaborate with the care team to ensure medical necessity and proper documentation for payer reviews.

Daily duties include performing UM reviews, coordinating with physicians, expediting discharge, and documenting in EMR. A BSN and 3 years UM experience are preferred, with CCM/ ACM and BLS desirable.