Utilization Review Specialist (RN) - Hybrid in Traverse City, MI

Munson Healthcare•Traverse City, MI

7h•Hybrid

About The Position

The Utilization Review Specialist (RN) ensures appropriate utilization of healthcare services across the continuum of care. The role evaluates patient admissions, continued stays, and transitions of care for compliance with regulatory requirements, payer guidelines, and evidence-based standards of practice. In collaboration with physicians, case managers, nursing staff, payers, and interdisciplinary teams, the specialist supports high-quality, cost-effective patient care, appropriate reimbursement, and organizational performance. The position is hybrid in Traverse City, Michigan, with the first eight weeks of estimated training onsite, Monday through Friday, 8:00 a.m. to 4:30 p.m. Once established, the work arrangement is 50/50 hybrid and onsite. The regular schedule is typically Monday through Friday, 2:00 p.m. to 10:30 p.m., with a weekend rotation every four to five weekends and rotating holiday work as needed. Locations include MMC ED and Copper Ridge.

Requirements

Current Registered Nurse (RN) licensure in the State of Michigan.
At least three years of clinical experience.
Strong clinical assessment, critical-thinking, and decision-making skills.
Effective verbal and written communication skills.
Proficiency in Microsoft Office, Outlook, and related computer applications.
Ability to independently organize workload, manage competing priorities, and meet deadlines.
Demonstrated attention to detail and problem-solving abilities.
Employees must be vaccinated or have lab-confirmed immunity for measles, mumps, rubella, and varicella. Employees must also receive an annual flu vaccine during flu season or have an approved medical or religious exemption.

Nice To Haves

Previous utilization review, utilization management, or case management experience in a hospital or insurance setting.
Knowledge of managed care, Medicare, Medicaid, HMOs, and reimbursement methodologies.
Experience with discharge planning and transitions of care.
Experience with EHR Cerner.

Responsibilities

Review admission documentation and assess whether patient status and services are appropriate to the patient’s condition and diagnosis.
Apply standard guidelines to determine whether inpatient or observation care is appropriate based on documented condition, treatment plan, and care.
Support physician decision-making by coaching on inpatient versus observation status and discussing alternatives when documentation does not support hospital-level care.
Refer unresolved cases with inadequate documentation to the Physician Advisor and monitor the timeliness of Physician Advisor responses.
Understand and apply federal requirements for Hospital Initiated Notice of Non-Coverage (HINN) and Ambulatory Benefit Notice (ABN), and monitor insurer compliance with contractual obligations.
Use electronic review applications, including CERMe and the EMR, and hospital information systems to access information and enter accurate, timely data.
Participate in daily huddles, patient care conferences, and hospitalist/nurse hand-off reports to remain informed about clinical status and care progression.
Work with case managers and Physician Advisors to address progression-of-care barriers through appropriate administrative and medical channels.
Identify potentially unnecessary services or care settings and recommend alternatives when appropriate.
Collaborate with community physicians and hospitalists to support transitions between levels of care.
Notify insurers and third-party administrators of clinical review information and maintain documentation supporting level of care and continued stay; perform status changes as necessary.
Identify and record preventable delays or avoidable days associated with failures in progression-of-care processes.
Promote physicians’ use of evidence-based protocols and order sets to support high-quality, cost-effective care.
Collaborate with the clinical team to confirm benefit eligibility for post-acute services and apply InterQual/Milliman discharge screens to assess readiness for a lower level of care.
Update involved parties about potential, threatened, or actual denials related to medical necessity or barriers to care progression.
Participate in reviews of 30-day readmissions as directed by the program manager.
Review direct admission and transfer requests for appropriate level of care; coordinate with the ED Case Manager on alternative placement when patients do not qualify for observation or inpatient status.
Serve as a resource to physicians, case managers, physician offices, and billing staff on coverage and compliance issues.
Work with decision support personnel to review resource utilization data and trends and identify opportunities for real-time coaching.
Encourage collaborative problem-solving among healthcare team members regarding appropriate resource use.
Assist in developing and revising utilization management policies, criteria, guidelines, clinical practice guidelines, and treatment protocols.
Recognize and respond appropriately to risk factors; stay current on regulatory changes affecting medical necessity or reimbursement and share updates with colleagues and hospital associates.
Represent Utilization Management on committees, professional organizations, physician groups, or community groups as appropriate.
Establish and maintain effective professional relationships with patients, families, interdisciplinary team members, payers, and external case managers.