RN Registered Nurse Utilization Review

Trinity Health•Ann Arbor, MI

About The Position

The Utilization Review Specialist is a Registered Nurse responsible for collecting patient clinical information and applying clinical criteria while considering patients’ clinical, age-specific, developmental, cultural, and spiritual needs. The specialist facilitates utilization management documentation and appropriate communication with external agencies and demonstrates designated area competencies. This is a contingent 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.

Requirements

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

Responsibilities

Complete utilization review documentation submissions for concurrent and retrospective patients within established timelines; ensure authorizations are obtained and communicated to ePFS teams promptly.
Identify and resolve errors in patient demographic and insurance information, coordinating with Revenue Cycle departments such as Insurance Clearance as needed.
Submit utilization review documentation for concurrent and retrospective Commercial and 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 promptly identifying concurrent or potential concurrent denials.
Communicate with the physician advisor, coordinate telephone appointments with payer Medical Directors, and electronically document outcomes.
Help ensure minimal medical necessity denials resulting from a lack of clinical review information sent to the payer.
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.