RN Utilization Rvw Spclst - Utilization Management

Kettering Health • Miamisburg, OH

2d • Onsite

About The Position

The RN Utilization Review Specialist role focuses on reviewing inpatient and observation admissions to ensure correct assignment of Admit status. This role communicates concurrently and resolves medical necessity discrepancies with physicians and other hospital leadership as needed. The specialist is responsible for completing clinical reviews on all assigned patients and communicating these reviews to payers. They also identify potential or actual denials for admission or ongoing stay, both during the patient’s hospital stay and post discharge. Additionally, the role involves reviewing and deciding the validity of medical necessity payer denials and submitting payer denial appeals. Participation in the design of work flows and procedures to reduce the incidence of denials is also a key aspect of this position.

Requirements

• Registered professional nurse with education, knowledge and experience.
• Current unrestricted Ohio RN licensure.
• BSN required.
• Experience with computers required.

Nice To Haves

• 5 years clinical experience with 2 years case management
• Case Management certification
• Works independently
• Familiar with MCG Care guidelines
• Ability to adapt quickly to changing priorities and regulations
• Experience with Microsoft applications and EPIC software

Responsibilities

• Review of inpatient and observation admissions to ensure correct assignment of Admit status.
• Communicate concurrently and resolve medical necessity discrepancies with physicians and other hospital leadership.
• Complete clinical review on all assigned patients and communicate these reviews to payers.
• Identify potential or actual denials for admission or ongoing stay.
• Review and decide the validity of medical necessity payer denials.
• Submit payer denial appeals.
• Participate in the design of work flows and procedures to reduce the incidence of denials.

What This Job Offers

• Job Type: Part-time
• Career Level: Mid Level