Utilization Review Specialist Registered Nurse - Behavioral Health

McLaren Health Care; Bay City (MI); Vor Ort; USD 70.000 - 90.000; Vollzeit

Zusammenfassung

McLaren Health Care is seeking an UR Specialist RN to work with admitting physicians and the care team to determine admission status based on payer requirements and medical necessity. You will perform concurrent reviews, monitor hospital resources, and help ensure reimbursement is supported by documentation.

The role requires an active Michigan RN license and a nursing degree, with 2 years of clinical or utilization management experience. On-site hours are 7:00am–3:00pm, with no on-call duties.

Qualifikationen

• Requires Nursing degree from an accredited institution.
• Michigan RN license is required.
• Two years of recent clinical or utilization management experience.

Aufgaben

• Performs concurrent and retrospective utilization management reviews to ensure data is tracked, evaluated and reported.
• Collaborates with health care team to determine inpatient vs. outpatient setting based on medical necessity.
• Works with case management to expedite patient discharge and optimize hospital reimbursement.

Kenntnisse

Clinical documentation

Healthcare compliance

Collaboration

Ausbildung

Nursing degree from an accredited institution

State of Michigan RN license

Tools

Electronic Medical Records

Jobbeschreibung

The McLaren system includes 12 hospitals across the state, ambulatory surgery centers, imaging centers, a 730-member employed primary and specialty care physician network, commercial and Medicaid HMOs covering more than 242,000 Michigan lives, home health, infusion and hospice providers, pharmacy services, a clinical laboratory network, and a wholly owned medical malpractice insurance company. McLaren operates Michigan’s largest network of cancer centers and providers, anchored by the Karmanos Cancer Institute, a National Cancer Institute-designated comprehensive cancer center. McLaren has 20,000 full-, part-time and contracted employees and more than 93,000 network providers throughout Michigan.

In conjunction with the admitting/attending physician, the UR Specialist RN assists in determining the appropriate admission status based on the regulatory and reimbursement requirements of various commercial and government payers. Partners with the health care team to ensure reimbursement of hospital admissions is based on medical necessity and documentation is sufficient to support the level of care being billed . Conducts concurrent reviews as directed in the hospital’s UR Plan of medical records to ensure criteria for admission and continued stay are met and documented. Along with other health care team members, monitors the use of hospital resources and identifies delays. Reports delays to leadership for resolution.

Job Specific Duties and Responsibilities

Performs a variety of concurrent and retrospective utilization management-related reviews and functions to ensure that appropriate data are tracked, evaluated, and reported.

• Collaborates with the health care team to determine the appropriate hospital setting (inpatient vs. outpatient) based on medical necessity. Actively seeks additional clinical documentation from the physician to optimize hospital reimbursement when appropriate.
• Works collaboratively with case management to expedite patient discharge.
• Maintains current knowledge of hospital utilization review processes and participates in the resolution of retrospective reimbursement issues including appeals, PACER authorization, third party payer certification, and denied cases.
• Assists with monitoring the effectiveness/outcomes of the utilization management program, identifying and applying appropriate metrics, evaluating the data, reporting results to various audiences, and designing and implementing process improvement projects as needed.
• Identifies, develops, and provides orientation, training, and competency development for appropriate staff and colleagues on an ongoing basis.
• Analyzes, updates, and modifies procedures and processes to continually improve utilization review operations.
• Maintains professional and technical knowledge by attending educational workshops; reviewing professional publications; establishing personal networks; participating in professional societies.
• Complies with federal, state, and local legal and certification requirements by studying existing and new legislation; anticipating future legislation; enforcing adherence to requirements; advising management on needed actions.
• Performs other related duties as required and directed.

Required

• Nursing degree from an accredited educational institution
• State of Michigan licensure as a Registered Nurse (RN)
• Two years of recent clinical or utilization management experience

Preferred:

• Bachelor’s degree in nursing.
• Three years of recent case management or utilization management experience

Additional Information

• Requisition ID: 26004747
• Daily Work Times: 7:00am - 3:00pm
• On Call: No

McLaren Health Care is an Equal Opportunity Employer. Qualified applicants will receive consideration for employment without regard to race, color, religion, sexual orientation, gender identification, age, sex, marital status, national origin, disability, genetic information, height or weight, protected veteran or other classification protected by law.

McLaren Health Care is an Equal Opportunity Employer. Qualified applicants will receive consideration for employmentwithout regard to race, color, religion, sexual orientation, gender identification, age, sex, marital status,national origin, disability, genetic information, height or weight, protected veteran or other classificationprotected by law.