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

Munson Healthcare•Traverse City, MI

24d•Hybrid

About The Position

The Utilization Review Specialist (RN) ensures appropriate utilization of healthcare services across the continuum of care. The role evaluates admissions, continued stays, and transitions of care for compliance with regulatory requirements, payer guidelines, and evidence-based standards. Working with physicians, case managers, nursing staff, payers, and interdisciplinary teams, the specialist promotes high-quality, cost-effective care while supporting appropriate reimbursement and organizational performance. The position is hybrid in Traverse City, Michigan, with the first eight weeks of training onsite. Once established, the schedule is 50/50 hybrid and onsite. Typical hours are Monday through Friday, 2:00 p.m.–10:30 p.m., with a weekend rotation every four to five weekends and rotating holiday work as needed. Work locations include MMC ED and Copper Ridge. The specialist reviews admissions and continued stays, supports decisions about inpatient or observation status, communicates with physicians and payers, documents clinical criteria, identifies avoidable delays, and helps coordinate transitions to appropriate post-acute care. The role also supports utilization management programs through policy development, regulatory updates, resource-use reviews, and collaboration with clinical and administrative colleagues.

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.
Attention to detail and problem-solving abilities.
Vaccination or lab-confirmed immunity for Measles, Mumps, Rubella, and Varicella; employees must also receive an annual flu vaccine 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 the Cerner EHR.

Responsibilities

Review admissions and available documentation to assess appropriate patient status and services based on condition, diagnosis, treatment plan, and applicable guidelines.
Support physician decisions about inpatient versus observation status, discuss alternatives when documentation does not support hospital-level care, and refer unresolved cases to the Physician Advisor.
Apply federal requirements related to 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 record data accurately and promptly.
Participate in daily huddles, patient care conferences, and hand-off reports to remain informed about clinical status and care progression.
Work with case managers and Physician Advisors to resolve barriers to care progression 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, and notify insurers and third-party administrators of clinical review information.
Document criteria supporting the appropriate level of care and continued stay; perform status changes as needed.
Refer cases to the Physician Advisor when treatment-plan documentation does not support acute care, and monitor the timeliness of responses.
Identify and record preventable delays or avoidable days related to care-progression processes.
Promote the use of evidence-based protocols and order sets to support high-quality, cost-effective care.
Confirm benefit eligibility for post-acute services and use 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, and coordinate with the ED Case Manager on alternate placement recommendations when observation or inpatient criteria are not met.
Serve as a resource for physicians, case managers, physician offices, and billing staff on coverage and compliance issues.
Work with decision-support personnel to review resource-use data and trends and identify opportunities for real-time coaching.
Encourage collaborative problem-solving among healthcare team members regarding appropriate resource use.
Assist with 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 relevant information with colleagues.
Represent Utilization Management on committees, professional organizations, and physician or community groups as needed.
Establish and maintain effective professional relationships with patients, families, interdisciplinary team members, payers, and external case managers.