Concurrent Denial Nurse BU - Utilization Management

Cleveland Clinic

3d•Remote

About The Position

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. Join the Cleveland Clinic team where you will work alongside passionate caregivers and provide patient-first healthcare. You will work alongside dedicated caregivers, receive endless support and appreciation, and build a rewarding career with one of the most respected healthcare organizations in the world. As a Concurrent Denial Nurse, you will support the Utilization Management Department by reviewing concurrent and retrospective clinical inpatient denials to ensure medical necessity criteria is met. We are looking for a Registered Nurse who is a subject matter expert in utilization management, has experience with MCG criteria, and is comfortable educating Caregivers and Physicians. In this role, you will get to work with a dynamic team of like-minded professionals and gain experience at an elite healthcare organization. A caregiver in this position works days from 7:30AM – 4:30PM. A caregiver who excels in this role will: Serve as the expert in Utilization Management functions and be a resource to the department in general and the hospital. Review and analyze concurrent and retrospective clinical denials and follow the specific payer processes. Serve as an expert in payer specific process and communicate between payer and CCIRH to identify/resolve denial process issues. Work in collaboration with the local physician advisor team and support the peer-to-peer process. Perform the routine activities of a UM Specialist when needed while taking a leadership role. Utilize knowledge of medical terminology, anatomy and physiology, diagnosis, surgical procedures and basic disease processes. Utilize knowledge and experience with Care Guidelines and /or other UM criteria sets. Utilize advanced interpersonal and communication written and verbal skills necessary to gather and exchange data (both internally and externally) with members of the health care team. Recommend resource utilization when needed Utilize analytical skills to gather data, identify problems and facilitate resolution. Prioritize and organize work to meet changing priorities. Utilize knowledge of multiple hospital information systems and department’s software. Assist with education and monitoring of UM specialist's reviews. Participate in payer specific p2p calls or local meetings as needed.

Requirements

Completion of an accredited Registered Nursing Program (RN)
Current valid license in the State of Florida as a Registered Nurse (RN)
Basic Life Support (BLS) certification through the American Heart Association (AHA) or American Red Cross
Three years of full-time Utilization Management experience
Demonstrated above average competence in Utilization Management Processes

Nice To Haves

Case Management certification (CCM or ACM)
Bachelor’s Degree in Nursing or related field

Responsibilities

Serve as the expert in Utilization Management functions and be a resource to the department in general and the hospital.
Review and analyze concurrent and retrospective clinical denials and follow the specific payer processes.
Serve as an expert in payer specific process and communicate between payer and CCIRH to identify/resolve denial process issues.
Work in collaboration with the local physician advisor team and support the peer-to-peer process.
Perform the routine activities of a UM Specialist when needed while taking a leadership role.
Utilize knowledge of medical terminology, anatomy and physiology, diagnosis, surgical procedures and basic disease processes.
Utilize knowledge and experience with Care Guidelines and /or other UM criteria sets.
Utilize advanced interpersonal and communication written and verbal skills necessary to gather and exchange data (both internally and externally) with members of the health care team.
Recommend resource utilization when needed
Utilize analytical skills to gather data, identify problems and facilitate resolution.
Prioritize and organize work to meet changing priorities.
Utilize knowledge of multiple hospital information systems and department’s software.
Assist with education and monitoring of UM specialist's reviews.
Participate in payer specific p2p calls or local meetings as needed.