Utilization Review Nurse - Case Management Days - 32hrs/wk.

umhealthwest•Wyoming, MI

About The Position

The Utilization Review Nurse performs clinical reviews using accepted screening criteria to assess medical necessity, appropriateness of health care services, hospital resource utilization, and quality of patient care at University of Michigan Health West. The role combines clinical, business, and regulatory knowledge to reduce financial risk and exposure from concurrent and retrospective denials of payment for services provided. The position conducts utilization management across neonate, pediatric, adolescent, adult, and geriatric populations; collaborates with payers, physician advisors, and the health care team; and supports strategies to improve length of stay, resource use, patient outcomes, and appropriate clinical documentation. It also collects and reports performance and financial indicators and contributes to utilization review process improvement.

Requirements

Current and valid Michigan R.N. license.
Minimum of three years of acute clinical nursing experience.
Skill and proficiency in applying managed care principles and concepts to the utilization review process.
Skill in observation and critical thinking, demonstrated through effective decision-making and appropriate problem-solving methods.
Excellent interpersonal, oral, and written communication skills.
A high degree of professionalism when interacting with patients, family members, clinical personnel, physicians, outside referral sources, and community members.
Ability to make effective decisions and judgments and incorporate problem-solving methods.
Ability to persist in working through and resolving issues and problems.
Ability to work independently and professionally, set priorities, take initiative, work efficiently, and use good judgment.

Nice To Haves

Bachelor of Science in Nursing.
Knowledge of and skill in using computers and related systems and software.

Responsibilities

Assess medical documentation for medical necessity using established criteria and determine the appropriate level of care for neonate, pediatric, adolescent, adult, and geriatric patients.
Refer cases to the Physician Advisor for medical necessity review when appropriate.
Explore and implement strategies to reduce length of stay and resource consumption while maintaining optimal patient outcomes.
Obtain authorization for unscheduled and emergency admissions as directed by health plans, for in-network and out-of-network payers.
Communicate with surgical providers’ offices to ensure authorization is obtained for planned surgical procedures.
Provide key clinical information to payers to obtain authorizations as needed.
Collaborate with the health care team regarding length of stay, treatment, and patient classification implications.
Identify potential medical necessity denials in real time, draft and submit appeals, and seek guidance from leadership or the physician advisor as needed.
Communicate with payers to obtain insurance authorization, schedule peer-to-peer reviews, review medical necessity denials, and submit appeals.
Assist with educating medical staff and other health care professionals about resource utilization, regulations affecting care delivery, payer requirements, and patient classifications.
Verify and document utilization review outcomes, payer responses, and physician recommendations in the electronic record.
Assist in collecting and reporting resource and financial indicators, including case mix index, length of stay, avoidable days, readmission rates, denials, and appeals.
Collect delay and other data for performance or outcome indicators as determined by the Director of Care Management.
Use data to drive utilization review process improvement strategies.
Collaborate with medical staff, nursing staff, and other organizational members to support cost-efficient care in the appropriate setting.
Support and assist with appropriate clinical documentation efforts.
Review medical records for issues related to quality, risk management, and appropriate utilization of services.
Maintain predictable and reliable attendance.
Maintain current knowledge of department processes, protocols, and procedures; pursue self-directed learning and continuing education; and participate in committees, task forces, and work groups as determined by management.
Perform other duties as assigned.