Utilization Review Nurse- Utilization Management

MetroHealth; Cleveland (OH); In loco; USD 70.000 - 95.000; Tempo pieno

Descrizione del lavoro

MetroHealth is seeking a Utilization Review Nurse to support the physician and interdisciplinary team at patient entry. You will review inpatient admission criteria and observation status, contributing to a systematic denial management process to reduce revenue loss while maintaining high-quality care.

Ideal candidates hold a Bachelor's in Nursing with an Ohio RN license and at least five years of clinical experience.

Competenze

• Bachelor's degree in Nursing; Ohio RN license.
• Minimum five years of clinical nursing experience.
• Knowledge of medical necessity criteria for inpatient admission and observation.
• Experience with denials based on medical necessity or severity of illness.
• Strong communication, negotiation, and analytical skills.
• Familiarity with utilization management and case management.

Mansioni

• Support physician and interdisciplinary team in patient care at entry.
• Perform initial clinical review for inpatient admission and observation.
• Collaborate to develop denial management strategies to reduce revenue loss.
• Participate in denial management to improve reimbursement and patient care alignment.
• Uphold MetroHealth System mission and standards.

Conoscenze

Interdisciplinary teamwork

Analytical skills

Communication skills

Utilization management

Formazione

Bachelor's degree in Nursing

Strumenti

Milliman Health Management Guidelines

Descrizione del lavoro

Location:

METROHEALTH MEDICAL CENTER

Biweekly Hours:

80.00

Shift:

7a-330p

The MetroHealth System is redefining health care by going beyond medical treatment to improve the foundations of community health and well-being: affordable housing, a cleaner environment, economic opportunity and access to fresh food, convenient transportation, legal help and other services. The system strives to become as good at preventing disease as it is at treating it. Founded in 1837, Cuyahoga County's safety-net health system operates four hospitals, four emergency departments and more than 20 health centers.

Summary:

Responsible for supporting the physician and interdisciplinary team in the provision of patient care by ensuring the appropriate level of care at the point of entry. The utilization review nurse will work on defined patient populations and is responsible for an initial clinical review at the point of patient entry to the inpatient care setting, this includes observation status. Will collaborate with other interdisciplinary team members to develop and participate in a systematic approach to denial management, and in so doing reduce organizational exposure to revenue loss. Actively participates in the denial management process; improve reimbursement by optimizing revenue recovery due to inappropriate level of care, failure to meet medical necessity, and/or severity of illness. Upholds the mission, vision, values, and customer service standards of The MetroHealth System.

Qualifications:

Required: Bachelor's degree in Nursing (applies to placements after 1/1/2017). Current Registered Nurse License State of Ohio. Minimum of five years clinical experience. Able to work independently and as a member of an interdisciplinary team. Knowledge and experience with medical necessity criteria for inpatient admission and observation placement. Knowledge and experience of denials based on the absence of documented medical necessity or failure to meet severity of illness and intensity of service criteria. Knowledge of internal criteria set and Milliman Health Management Guidelines. Excellent interpersonal communication and negotiation skills. Strong analytical, data management, and PC skills. Current working knowledge of, utilization management, case-management, performance improvement, and managed care reimbursement. Strong organizational and time management skills. Preferred: Two years of experience with case management, utilization review. Physical Demands: May need to move around intermittently during the day, including sitting, standing, stooping, bending, and ambulating. May need to remain still for extended periods, including sitting and standing. Ability to communicate in face-to-face, phone, email, and other communications. Ability to read job related documents. Ability to use computer.