Utilization Review RN: Optimize Admissions & Reimbursement

Mclaren-Health-Care; Bay City (MI); On-site; USD 70,000 - 95,000; Full time

Job summary

McLaren Health Care in Grand Blanc, Michigan, seeks a Utilization Review (UR) Specialist RN to support admission decisions and ensure medical necessity documentation for payer reimbursement. You will collaborate with the health care team to determine inpatient vs outpatient settings and to expedite discharge when appropriate.

The role requires an active Michigan RN license, a nursing degree, and at least two years in clinical or utilization management; a Bachelor’s and three years UR experience

Qualifications

• Nursing degree from an accredited institution.
• Active RN license in Michigan.
• Two years of recent clinical or utilization management experience.
• Bachelor's degree in nursing preferred.
• Three years of UR or case management experience preferred.

Responsibilities

• Collaborate with health care team to determine inpatient vs outpatient settings based on medical necessity.
• Assist in determining admission status and ensure documentation supports reimbursement.
• Monitor utilization review processes and identify opportunities for process improvement.
• Assist with discharge planning to optimize patient flow and resource use.
• Maintain knowledge of regulatory requirements and payer rules.
• Provide orientation and training for staff on UR processes.

Skills

Utilization review

Nursing judgment

Collaboration

Education

Bachelor's degree in Nursing

Tools

PACER authorization

Job description

McLaren Health Care in Grand Blanc, Michigan, seeks a Utilization Review (UR) Specialist RN to support admission decisions and ensure medical necessity documentation for payer reimbursement. You will collaborate with the health care team to determine inpatient vs outpatient settings and to expedite discharge when appropriate.

The role requires an active Michigan RN license, a nursing degree, and at least two years in clinical or utilization management; a Bachelor’s and three years UR experience