RN Utilization Rvw Spclst - Utilization Management

Kettering Health • Miamisburg, OH

1d • Onsite

About The Position

The RN Utilization Review Specialist role focuses on the review of 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 review on all assigned patients and communicating these reviews to payers. They will identify potential or actual denials for admission or ongoing stay both during the patient’s hospital stay and post discharge, and review and decide the validity of medical necessity payer denials. The role also involves submitting payer denial appeals and participating in the design of work flows and procedures to reduce the incidence of denials.

Requirements

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

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.

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 both during the patient’s hospital stay and post discharge.
• 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