Registered Nurse - Utilization Management

McLaren Health Care•Mount Clemens, MI

1d•Remote

About The Position

The Registered Nurse - Utilization Management determines appropriate patient status based on regulatory and reimbursement requirements of commercial and government payers, in collaboration with admitting and attending physicians. The role partners with the health care team to ensure hospital admissions meet medical-necessity requirements and have sufficient documentation to support the level of care billed. The nurse conducts concurrent reviews to ensure criteria for patient status and continued stay are met and documented, monitors hospital resource use with the health care team, identifies delays, and reports delays to leadership for resolution. The position performs concurrent and retrospective utilization management reviews, collaborates with clinicians on care setting and documentation, supports discharge planning, and documents clinical reviews and related information in the electronic medical record and other applications. It also facilitates payer-provider peer reviews, participates in interdisciplinary case reviews, supports resolution of reimbursement issues, and contributes to program monitoring, process improvement, staff orientation, and training. The department is described as remote, with occasional in-person work. The schedule is 80 hours bi-weekly, with daily work times of 8 a.m. to 4 p.m.

Requirements

State licensure as a registered nurse (RN).
Bachelor’s degree in nursing from an accredited educational institution, or actively pursuing the degree with completion within five years of accepting the position.
Three years of recent nursing or utilization management experience with an acute care hospital.

Nice To Haves

Experience in utilization management or case management, critical care, clinical documentation, or patient outcomes or quality management.
Case management certification (ACM or CCM).
Basic Life Support (BLS) certification as a Healthcare Provider through the American Heart Association, American Red Cross, or equivalent through the Military Training Network (MTN).

Responsibilities

Perform concurrent and retrospective utilization management reviews and related functions to ensure appropriate data are tracked, evaluated, and reported.
Collaborate with the health care team to determine the appropriate hospital setting (inpatient versus outpatient) based on medical necessity.
Seek additional clinical documentation from physicians when appropriate to optimize hospital reimbursement.
Work with ICM service lines to expedite patient discharge.
Screen physician documentation and order entry for timeliness, appropriateness, and completeness related to level of care, medical necessity, and third-party payer requirements.
Document clinical reviews, payer authorizations, avoidable days, readmission risks, continued-stay reviews, and potential discharge dates in the electronic medical record and other applications.
Facilitate peer-to-peer reviews with payers and providers.
Participate in clinical case reviews and interdisciplinary rounds concerning continued-stay reviews and length-of-stay outliers.
Collaborate with providers and the physician advisor when medical necessity or appropriateness of care is questioned, following established procedures.
Maintain current knowledge of hospital utilization review processes and participate in resolving retrospective reimbursement issues, including appeals, PACER authorization, third-party payer certification, and denied cases.
Help monitor utilization management program outcomes, identify and apply metrics, evaluate data, report results, and design and implement process-improvement projects as needed.
Assist with ongoing orientation, training, and competency development for appropriate staff and colleagues.
Perform other related duties as required and directed.