Job Information
McLaren Health Care Utilization Review Specialist Registered Nurse - McLaren Careers in Bay City, Michigan
Department:
BAY 3 W Geropsych
Daily Work Times: 7:30am-4:00pm
Shift: Days
Scheduled Bi-Weekly Hours: 80
Position Summary :
In conjunction with the admitting/attending physician, the UR Specialist RN assists in determining the appropriate admission status based on the regulatory and reimbursement requirements of various commercial and government payers. Partners with the health care team to ensure reimbursement of hospital admissions is based on medical necessity and documentation is sufficient to support the level of care being billed
.
Conducts concurrent reviews as directed in the hospital’s UR Plan of medical records to ensure criteria for admission and continued stay are met and documented.
Along with other health care team members, monitors the use of hospital resources and identifies delays.
Reports delays to leadership for resolution.
Essential Functions and Responsibilities:
1.
Performs a variety of concurrent and retrospective utilization management-related reviews and functions to ensure that appropriate data are tracked, evaluated, and reported.
Collaborates with the health care team to determine the appropriate hospital setting (inpatient vs. outpatient) based on medical necessity. Actively seeks additional clinical documentation from the physician to optimize hospital reimbursement when appropriate.
Works collaboratively with case management to expedite patient discharge.
Maintains current knowledge of hospital utilization review processes and participates in the resolution of retrospective reimbursement issues including appeals, PACER authorization, third party payer certification, and denied cases.
5.
Assists with monitoring the effectiveness/outcomes of the utilization management program, identifying and applying appropriate metrics, evaluating the data, reporting results to various audiences, and designing and implementing process improvement projects as needed.
Qualifications:
Required
Nursing degree from an accredited educational institution
State of Michigan licensure as a Registered Nurse (RN)
Two years of recent clinical or utilization management experience
Preferred:
Bachelor’s degree in nursing.
Three years of recent case management or utilization management experience
Equal Opportunity Employer of Minorities/Females/Disabled/Veterans
We are committed to encouraging and sustaining a work environment free of unlawful harassment, discrimination, and/or retaliation. We are an Affirmative Action/Equal Opportunity Employer committed to providing employment opportunity without regard to an individual’s race, color, age, religion, sex/pregnancy (including pregnancy/childbirth or pregnancy/childbirth-related conditions), sexual orientation, gender identity, national origin, disability, veteran status, genetic information, or any other status prohibited by applicable laws. We also make good faith efforts to recruit, hire, and promote qualified women, minorities, individuals with disabilities, and veterans.
