Utilization Management RN Reviewer

ccf; United States; À distance; USD 75 000 - 105 000; Plein temps

Résumé du poste

Cleveland Clinic Health System is seeking an experienced Utilization Management RN Reviewer to work remotely with a focus on admission, concurrent and retrospective reviews. The role supports payer communications, data collection, and clinical decision-making to ensure appropriate resource use.

Ideal candidates are RNs with strong clinical judgment, knowledge of UM criteria, and proficiency with Microsoft Office.

Qualifications

• Graduate of an accredited school of nursing.
• Current state licensure as an RN.
• Basic Life Support (BLS) certification through AHA or Red Cross.
• Three years of full-time RN clinical experience.
• Knowledge of medical terminology, anatomy and physiology, diagnosis, procedures and basic disease processes.
• Analytical ability to gather data and decide conformity to criteria.
• Basic knowledge of medical records coding standards.
• Awareness of licensing and accreditation standards.
• Proficient with Microsoft Office.
• Knowledge of Care Guidelines and Medical Necessity Criteria and UM criteria sets.
• Ability to assess medical records and determine length of stay and discharge procedures.

Responsabilités

• Perform UM activities: admission review, concurrent and retrospective chart review.
• Review medical records and provide clinical information to payers.
• UM data collection and reporting responsibilities.
• Participate in focused reviews and opportunities for improvement.
• Document UR processes and maintain UM notes with evidence.

Connaissances

RN

Analytical thinking

Medical terminology

Medical records review

Care Guidelines

Medical Necessity Criteria

Microsoft Office

Billing knowledge

UM criteria

Hospital information systems

Formation

Bachelor of Science in Nursing (BSN)

Registered Nurse licensure

BLS certification

Case Management Certification (CCM)

Description du poste

At Cleveland Clinic Health System, we believe in a better future for healthcare. And each of us is responsible for honoring our commitment to excellence, pushing the boundaries and transforming the patient experience, every day.

We all have the power to help, heal and change lives - beginning with our own. That's the power of the Cleveland Clinic Health System team, and The Power of Every One.

Job Title

Utilization Management RN Reviewer

Location

Cleveland

Facility

Remote Location

Department

Utilization And Quality Assur-Weston Hospital

Job Code

000446

Shift

Days

Schedule

7:30am-4:00pm

Job Summary

Join the Cleveland Clinic team, where you will work alongside passionate caregivers and provide patient-first healthcare. Cleveland Clinic is recognized as one of the top hospitals in the nation. At Cleveland Clinic, you will receive endless support and appreciation and build a rewarding career with one of the most respected healthcare organizations in the world.

Utilization Management (UM) Specialists perform UM activities, such as admission review, concurrent review, retrospective chart review and clinical systems review to measure clinical performance and UM issues that affect reimbursement for the patient's hospital stay or visit. Some of the responsibilities of a Utilization Management Specialist include medical record review, providing clinical information to payers, UM data collection and reporting, concurrent denials appeals process, clinical team interaction, Physician Adviser interaction and special projects.

A caregiver in this role works remotely from 7:30 a.m. - 4:00 p.m. with weekend requirements. This remote role is limited to Florida, Ohio, and Nevada. Candidates must live within one hour of a Cleveland Clinic hospital to be eligible.

• A caregiver who excels in this role will:
• Recommend resource utilization.
• Prioritize and organize work to meet changing priorities.
• Utilize analytical abilities required to gather data.
• Use clinical judgment to apply predetermined criteria or use independent clinical judgment when no predetermined criteria exist to identify problems, facilitate resolution, recommend corrective action, and report results effectively.
• Use independent clinical judgment in reviewing records to determine status of patients stay, if proper procedures have been followed, seriousness of incidents and ability to identify need for and participate in focused reviews, special projects and identify opportunities for improvement.
• Make recommendations regarding appropriateness of the treatment plan for continued stay and safety of the discharge plan.
• Achieve a minimum of 85% on IRR quarterly.
• Complete utilization management for assigned patients with at least 25-30 reviews per day.
• Apply medical necessity guidelines accurately to monitor appropriateness of admission and continued stays.
• Document appropriately in UM notes to provide evidence that the UR process for the case was followed.
• Attend all staff meeting when scheduled to work.
• Other duties as assigned.

Minimum qualifications for the ideal future caregiver include:

• Graduate of an accredited school of nursing
• Current state licensure as a Registered Nurse (RN)
• Basic Life Support (BLS) certification through the American Heart Association (AHA) or American Red Cross
• Three years of equivalent full-time clinical experience as a Registered Nurse
• Knowledge of medical terminology, anatomy and physiology, diagnosis, surgical procedures, and basic disease processes
• Analytical ability to gather data, decide on conformity based on predetermined criteria, identify problems and refer for resolution
• Basic knowledge of medical records coding standards
• Awareness of licensing and accreditation standards
• Proficient with Microsoft Office
• Knowledge of billing practices, identification of billing problems, adequacy of documentation, and ability to conduct research of issue at hand, as well as formulate recommendations based on findings.
• Knowledge and experience with Care Guidelines, Medical Necessity Criteria and/or other UM criteria sets
• Ability to assess medical records and make determinations on length of stay and proper procedures in accordance with policies and procedures
• Knowledge of and ability to use multiple Hospital information systems and Department's software
• Ability to use copier, fax machine and personal computer

Preferred qualifications for the ideal future caregiver include:

• Bachelor of science in nursing (BSN)
• Case Management Certification (CCM) preferred within first year of eligibility
• Prior Utilization Management experience
• Case management or ED experience
• Emergency room experience

Physical Requirements:

• Requires walking, sitting, and/or standing for long periods of time.
• Requires constant attention to detail, reading of medical records, and meeting deadlines.
• Works in an environment where there is some discomfort due to dust, noise, temperature.

Personal Protective Equipment:

Follows standard precautions using personal pr