Utilization Review Nurse-Utilization Management

Location: METROHEALTH MEDICAL CENTER

Biweekly Hours: 80.00

Shift: Days; Rotating Weekends and Holidays

The MetroHealth System is redefining health care by going beyond medical treatment to improve the foundations of community health and well-being: affordable housing, a cleaner environment, economic opportunity and access to fresh food, convenient transportation, legal help and other services. The system strives to become as good at preventing disease as it is at treating it. Founded in 1837, Cuyahoga County’s safety-net health system operates four hospitals, four emergency departments and more than 20 health centers.

Summary

Responsible for supporting the physician and interdisciplinary team in the provision of patient care by ensuring the appropriate level of care at the point of entry. The utilization review nurse will work on defined patient populations and is responsible for an initial clinical review at the point of patient entry to the inpatient care setting, this includes observation status. Will collaborate with other interdisciplinary team members to develop and participate in a systematic approach to denial management, and in so doing reduce organizational exposure to revenue loss. Actively participates in the denial management process; improve reimbursement by optimizing revenue recovery due to inappropriate level of care, failure to meet medical necessity, and/or severity of illness. Upholds the mission, vision, values, and customer service standards of The MetroHealth System.

Qualifications

Required: Bachelor’s degree in Nursing (applies to placements after 1/1/2017). Current Registered Nurse License State of Ohio. Minimum of five years clinical experience. Able to work independently and as a member of an interdisciplinary team. Knowledge and experience with medical necessity criteria for inpatient admission and observation placement. Knowledge and experience of denials based on the absence of documented medical necessity or failure to meet severity of illness and intensity of service criteria. Knowledge of internal criteria set and Milliman Health Management Guidelines. Excellent interpersonal communication and negotiation skills. Strong analytical, data management, and PC skills. Current working knowledge of, utilization management, case-management, performance improvement, and managed care reimbursement. Strong organizational and time management skills. Preferred: Two years of experience with case management, utilization review. Physical Demands: May need to move around intermittently during the day, including sitting, standing, stooping, bending, and ambulating. May need to remain still for extended periods, including sitting and standing. Ability to communicate in face-to-face, phone, email, and other communications. Ability to read job related documents. Ability to use computer.