RN Utilization Review Specialist - Hybrid Impact Role

Munson Healthcare; Michigan; Hybrid; USD 70,000 - 95,000; Full time

Job summary

Munson Healthcare in northern Michigan is seeking an experienced Utilization Review Specialist (RN) to ensure appropriate utilization across the continuum of care. You will evaluate admissions, continued stays, and transitions, coordinating with physicians, case managers, and payers to support high-quality, cost-effective care and proper reimbursement.

The role requires current Michigan RN licensure, at least three years of clinical experience, strong assessment and decision-making skills, and

Qualifications

• Current RN licensure in Michigan.
• Minimum of three years clinical experience.
• Strong clinical assessment, critical thinking, and decision-making skills.
• Effective verbal and written communication skills.
• Proficiency in Microsoft Office, Outlook, and related computer applications.
• Ability to independently organize workload, manage priorities, and meet deadlines.
• Attention to detail and problem-solving abilities.

Responsibilities

• Reviews admissions for appropriate status and services.
• Applies guidelines to determine inpatient vs observation status.
• Coaches physicians on appropriateness of inpatient/observation status.
• Consults with admitting physician when documentation does not support level of care.
• Notifies insurers of clinical review information.
• Maintains proficiency in CERMe and EMR and accurate data entry.
• Maintains hospital information systems to access information and record data.
• Participate in daily huddles and care conferences.
• Resolve progression-of-care barriers with case manager/physician advisor.
• Identify potentially unnecessary services and recommend alternatives.
• Collaborate with community physicians to influence transitions of care.
• Promote evidence-based protocols to improve care.
• Confirm benefit eligibility for post-acute services.
• Apply discharge screens to assess readiness for a lower level of care.
• Update parties on potential denials due to lack of medical necessity.
• Review 30-day Readmissions as directed by program manager.
• Review direct admissions and transfers for appropriate level of care.
• Coordinate with ED Case Manager for alternate placement.

Skills

RN licensure

Clinical experience

Communication skills

MS Office

Tools

Cerner EHR

Job description

Munson Healthcare in northern Michigan is seeking an experienced Utilization Review Specialist (RN) to ensure appropriate utilization across the continuum of care. You will evaluate admissions, continued stays, and transitions, coordinating with physicians, case managers, and payers to support high-quality, cost-effective care and proper reimbursement.

The role requires current Michigan RN licensure, at least three years of clinical experience, strong assessment and decision-making skills, and