RN Utilization Management Specialist

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

Job summary

McLaren Health Care in Port Huron, MI seeks an RN for Utilization Management to determine patient status based on payer requirements, collaborating with the admitting physician to ensure medical necessity and documentation supports billing for the level of care.

The role includes concurrent and retrospective reviews, discharge planning, documentation in the EMR, and peer-to-peer reviews with payers. The portfolio also covers LOS monitoring, process improvement, and ongoing staff training.

Qualifications

• State RN license
• Bachelor’s degree in nursing from an accredited institution, or pursuing with plan to obtain within five years
• Three years of recent nursing or utilization management experience in an acute care hospital

Responsibilities

• Performs concurrent and retrospective utilization management reviews to track, evaluate and report data
• Collaborates with health care team to determine inpatient vs. outpatient setting based on medical necessity
• Expedites patient discharge with ICM service lines and verifies timeliness and completeness of documentation for utilization management
• Documents clinical reviews, payer authorizations, avoidable days, readmission risks, and discharge dates in the EMR using multiple systems
• Facilitates peer-to-peer reviews with payers/providers and participates in interdisciplinary rounds regarding continued stays and LOS outliers
• Collaborates with providers when medical necessity and/or appropriateness of care is questioned following SOPs
• Maintains knowledge of utilization review processes and participates in resolving reimbursement issues including appeals and denials
• Assists with measuring effectiveness of the program and supporting process improvements and staff competency

Education

Bachelor’s degree in nursing

Job description

McLaren Health Care in Port Huron, MI seeks an RN for Utilization Management to determine patient status based on payer requirements, collaborating with the admitting physician to ensure medical necessity and documentation supports billing for the level of care.

The role includes concurrent and retrospective reviews, discharge planning, documentation in the EMR, and peer-to-peer reviews with payers. The portfolio also covers LOS monitoring, process improvement, and ongoing staff training.