Utilization Management Specialist

Cleveland Clinic • Cleveland, OH

69d

About The Position

Join the Cleveland Clinic team where you will work alongside passionate caregivers and provide patient-first healthcare. Here, you will receive endless support and appreciation while building a rewarding career with one of the most respected healthcare organizations in the world. As a Utilization Management Specialist, you will perform UM activities, such as admission, concurrent, retrospective chart and clinical systems reviews to measure clinical performance and issues that affect reimbursement for hospital stays or visits. This role is essential in the overall organizational and functional operations, helping advance and enhance the patient experience and delivery of care across the hospital.

Requirements

• Graduate of an accredited School of Nursing.
• Current state licensure as a Registered Nurse (RN).
• Basic Life Support (BLS) Certification through the American Heart Association (AHA).
• Knowledge of medical terminology, anatomy and physiology, diagnosis, surgical procedures and basic disease processes.
• Three years of equivalent full-time clinical experience as a Registered Nurse.
• Analytical ability required to gather data, decide on conformity based on predetermined criteria, identify problems and refer for resolution.
• Basic knowledge of medical records coding standards.
• Proficiency with Microsoft Office.
• Knowledge of billing practices, identification of billing problems and adequacy of documentation.
• Knowledge and experience with Care Guidelines, Medical Necessity Criteria and/or other UM criteria sets.
• Ability to assess medical records and make determinations on length of stay and proper procedures in accordance with policies and procedures.
• Demonstrated competence in all areas identified in the Competencies, Dimensions, Problem solving, and Information Management sections.
• Knowledge of and ability to use multiple Hospital information systems and Department's software.

Nice To Haves

• Case Management Certification (CCM).
• Prior Utilization Management experience.

Responsibilities

• Recommend resource utilization.
• Prioritize and organize work to meet changing priorities.
• Utilize analytical ability required to gather data, apply predetermined criteria, identify problems, facilitate resolution, recommend corrective action and report results effectively.
• Use independent clinical judgment in reviewing records to determine status of patients stay, if proper procedures have been followed, seriousness of incidents and ability to identify need for and participate in focused reviews, special projects and identify opportunities for improvement.
• Make recommendations regarding appropriateness of the treatment plan for continued stay and safety of the discharge plan.
• Achieve a minimum of 85% on IRR quarterly.
• Complete Utilization Management for assigned patients with a minimum of 25-30 reviews per day.
• Apply medical necessity guidelines accurately to monitor appropriateness of admission and continued stays.
• Maintain and support collaborative relationships with RN Case Manager, Physicians and the multidisciplinary team.
• Document appropriately in UM notes to provide evidence that the UR process for the case was followed.

What This Job Offers

• Job Type: Full-time
• Industry: Ambulatory Health Care Services
• Education Level: Bachelor's degree