RN Utilization Management Coordinator

Corewell Health • Southfield, MI

1d • Onsite

About The Position

This role includes accountability for utilization review (UR) and may include admission, concurrent, and retrospective reviews. Coordinates activities involved in the certification, recertification, and concurrent appeals process, conducting referrals for 2nd level review, as needed. Ensures timely communication with payers based on adequate and complete documentation received by the physician/provider and utilization reviews. Initiates concurrent appeals to address patient class/status downgrades or clinical denials related to medical necessity. Participates within the department to meet expected objectives and outcomes. Meets or exceeds expectations related to behavior and performance. Meets individual and departmental objectives established for Quality, Satisfaction, Growth and Financial Success. Conducts timely and accurate utilization reviews, as assigned, using organization-approved UR criteria. Works closely with physician advisors and medical staff to ensure appropriate level of care, including obtaining physician orders for patient class changes when needed. Refers cases, as defined, for 2nd level medical necessity review. Maintains daily contact with payers to obtain authorization and reauthorization information and addresses concurrent denials and/or audit requests. Provides UR and clinical documentation is adequate and complies with payer requirements. Schedules next review/follow-up reviews as required in accordance with organizational policy and procedure and payer requests. Routinely collaborates with the System Clinical Appeals and Revenue Cycle departments to expedite billing and appeals processes. Maintains and monitors assigned work queues within the Electronic Medical Record.

Requirements

• Associate's Degree or technical degree.
• 2 years of experience in a clinical/hospital setting.
• Hospital utilization review/utilization management experience.
• Registered Nurse (RN) - State of Michigan Upon Hire required.

Nice To Haves

• Bachelor's Degree in nursing or related field.
• Clinical appeals experience.

Responsibilities

• Accountable for utilization review (UR), including admission, concurrent, and retrospective reviews.
• Coordinates activities for certification, recertification, and concurrent appeals.
• Conducts referrals for 2nd level review as needed.
• Ensures timely communication with payers based on adequate and complete documentation.
• Initiates concurrent appeals for patient class/status downgrades or clinical denials.
• Participates within the department to meet expected objectives and outcomes.
• Meets or exceeds expectations related to behavior and performance.
• Meets individual and departmental objectives for Quality, Satisfaction, Growth, and Financial Success.
• Conducts timely and accurate utilization reviews using organization-approved UR criteria.
• Works closely with physician advisors and medical staff to ensure appropriate level of care.
• Obtains physician orders for patient class changes when needed.
• Refers cases for 2nd level medical necessity review.
• Maintains daily contact with payers for authorization and reauthorization information.
• Addresses concurrent denials and/or audit requests.
• Ensures UR and clinical documentation is adequate and complies with payer requirements.
• Schedules next review/follow-up reviews as required.
• Collaborates with System Clinical Appeals and Revenue Cycle departments.
• Maintains and monitors assigned work queues within the Electronic Medical Record.

Benefits

• Comprehensive benefits package to meet financial, health, and work/life balance goals.
• On-demand pay program powered by Payactiv.
• Discounts directory with deals on restaurants, phone plans, spas, and more.
• Optional identity theft protection, home and auto insurance.
• Traditional and Roth retirement options with service contribution and match savings.

What This Job Offers

• Job Type: Part-time
• Career Level: Mid Level
• Education Level: Associate degree