RN Registered Nurse Utilization Review

Trinity Health•Chelsea, MI

About The Position

The Utilization Review Specialist is a Registered Nurse responsible for collecting patient clinical information and applying clinical criteria while considering clinical, age-specific, developmental, cultural, and spiritual needs. The role facilitates utilization management documentation and appropriate communication with external agencies, and demonstrates designated area competencies. This is a contingent, part-time position providing weekday and weekend coverage. The schedule includes two shifts every other weekend and a holiday commitment approximately once every 18 months. Shifts are eight hours, with flexible start times generally between 6 a.m. and 9 a.m. Additional hours are available. The position completes utilization review documentation for concurrent and retrospective patients, coordinates payer reviews and authorization communications, and works with case managers, physician advisors, payer representatives, and revenue-cycle and other departments to support timely and accurate utilization management.

Requirements

Graduation from an accredited nursing program.
Current Registered Nurse (RN) license in the State of Michigan.
Two to three years of related experience and clinically relevant knowledge regarding the patient population.
For new hires effective January 1, 2013, a BSN degree is required, or the employee must agree in writing to obtain a BSN within five years from the date of hire.

Responsibilities

Complete utilization review documentation for concurrent and retrospective patients within established timelines.
Ensure authorizations are obtained and communicated to ePFS teams in a timely manner.
Identify and resolve errors in patient demographic and insurance information; coordinate with Revenue Cycle departments such as Insurance Clearance as needed.
Submit utilization review documentation for concurrent and retrospective Commercial, Managed Medicare, and Medicaid payer reviews.
Document in the electronic care management module the dates clinical reviews were sent and authorizations obtained.
Communicate appropriately with case managers and physician advisors.
Coordinate the peer-to-peer concurrent appeal process by timely identification of concurrent or potential concurrent denials.
Communicate with the physician advisor, coordinate telephone appointments with payer Medical Directors, and document outcomes electronically.
Help ensure minimal medical necessity denials due to missing clinical review information sent to payers.
Provide excellent customer service to payer representatives.
Maintain positive, collaborative relationships with Care Management, Physician Advisors, ePFS, Patient Access, Health Information Management, Insurance Clearance, and Patient Accounting to facilitate timely and accurate utilization management functions and prompt remuneration.
Identify process improvement opportunities as appropriate.
Accurately and completely document pertinent patient assessments, interventions, transitions, and outcomes in accordance with documentation standards, policies, procedures, and guidelines.