Utilization Review Nurse - Case Management (32 hrs/wk)

University of Michigan Health-West; Wyoming (MI); Presencial; USD 70.000 - 100.000; A tiempo parcial

Descripción de la vacante

The Utilization Review Nurse at University of Michigan Health West performs clinical reviews to determine medical necessity and appropriate level of care for diverse patient populations. This role blends clinical, business, and regulatory knowledge to manage resources and prevent denials of payment.

Responsibilities include obtaining authorizations, collaborating with the care team, and guiding documentation and appeals processes to support efficient, quality care delivery.

Formación

• Current and valid Michigan RN license; BSN preferred.
• Minimum of three years acute clinical nursing experience.
• Skill and proficiency in applying managed care principles to the utilization review process.
• Knowledge of and skill in the use of computers and related systems and software preferred.
• Skill in observation and critical thinking, with effective decision making and problem solving.
• Excellent interpersonal, oral, and written communication; high professionalism in all contacts.
• Ability to make effective decisions, set priorities, and work independently.

Responsabilidades

• Assess medical documentation for medical necessity using established criteria across neonate to geriatric populations.
• Refer cases to Physician Advisor for medical necessity review.
• Identify strategies to reduce length of stay and resource use while maintaining outcomes.
• Obtain authorizations for unscheduled admissions and communicate with providers to ensure authorization.
• Provide key clinical information to obtain payer authorizations as needed.
• Collaborate with care team on LOS and patient classification implications.
• Draft and submit denials appeals and seek guidance as needed.
• Document outcomes of utilization review and payer responses in the electronic record.
• Educate medical staff on payer requirements and resource utilization.

Conocimientos

RN license

Managed care

Critical thinking

Interpersonal comms

Computers & software

Independent work

Regulatory knowledge

Educación

BSN preferred

Herramientas

EMR systems

Microsoft Office

Descripción del empleo

The Utilization Review Nurse at University of Michigan Health West performs clinical reviews to determine medical necessity and appropriate level of care for diverse patient populations. This role blends clinical, business, and regulatory knowledge to manage resources and prevent denials of payment.

Responsibilities include obtaining authorizations, collaborating with the care team, and guiding documentation and appeals processes to support efficient, quality care delivery.