RN Utilization Review Specialist Priority Health

Corewell Health • Grand Rapids, MI

22h • Onsite

About The Position

Provides health information and serves as a resource for providers in complex clinical situations to support appropriate use of preservice and concurrent acute medical and behavioral health services. Assesses preservice and concurrent requests for admissions and continued stays, and completes medical necessity reviews for designated services across all Priority Health plans. Educates medical staff and other health care professionals about utilization management and quality requirements.

The specialist assesses and interprets clinical information and assists with case management for complex patients, using independent judgment, problem-solving skills, and applicable guidelines to evaluate the appropriate acute-care setting upon admission and during continued stays. The role works with inpatient care facilitators, Medical Social Workers, home health agencies, providers, physicians, and other team members to support appropriate movement through the continuum of care, continuity of services, work prioritization, and coordination. The specialist also supports process improvement and physician education, collaborates with Medical Directors, and ensures documentation and processes meet regulatory standards.

This is a full-time, onsite position at Priority Health in Grand Rapids, Michigan. The schedule is Monday through Friday, 8:00 a.m. to 5:00 p.m., for 40 hours per week.

Requirements

• Bachelor's degree or equivalent in nursing or a health care-related field.
• At least 2 years of relevant experience in acute care, clinical nursing, preferably across multiple clinical settings, or related experience.
• At least 5 years of post-licensure related experience in acute care, multiple clinical settings, or behavioral health, with utilization management, discharge planning, patient-centered care plan design, or related work.
• Registered Nurse (RN) license in the State of Michigan upon hire.

Responsibilities

• Assess the appropriateness of preservice and concurrent requests for admission and continued stay.
• Complete medical necessity reviews for designated services for all Priority Health plans.
• Assess and interpret clinical information and assist in case management of complex patients using independent judgment, problem-solving skills, and guidelines for appropriate acute-care admission and continued stay.
• Educate medical staff and other health care professionals regarding utilization management and quality requirements.
• Provide recommendations and financial, DRG, utilization management, and health information to care facilitation team members to support work prioritization.
• Work with inpatient care facilitators, Medical Social Workers, home health agencies, providers, physicians, and hospital personnel to support appropriate movement through the continuum of care.
• Communicate and collaborate with physicians and team members to ensure continuity and coordination of services.
• Discuss changes in level of care and alternatives for medically complex patients.
• Document instances in which services are delayed, inappropriate, refused, or complicated for resource management functions.
• Identify quality indicators to facilitate process improvement and physician education.
• Ensure members are authorized for the most appropriate level of care and services based on internal and external guidelines.
• Ensure documentation and processes are consistent with regulatory standards.
• Collaborate with Medical Directors.

Benefits

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

What This Job Offers

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