Utilization Management (UM) Reviewer RN

                    

At Cleveland Clinic Health System, we believe in a better future for healthcare. And each of us is responsible for honoring our commitment to excellence, pushing the boundaries and transforming the patient experience, every day.

                        

We all have the power to help, heal and change lives — beginning with our own. That’s the power of the Cleveland Clinic Health System team, and The Power of Every One.

                                    

Job Title

Utilization Management (UM) Reviewer RN

                        

Location

Cleveland

                    

Facility

Remote Location

                     

Department

NRS-Enterprise Utilization Mgmt-Nursing Institute

                      

Job Code

T2417E

                     

Shift

Days

                       

Schedule

8:00am-5:00pm

                       

Job Summary

                         

Job Details

Join the Cleveland Clinic team where you will work alongside passionate caregivers and provide patient-first healthcare. Here, you will receive endless support and appreciation while building a rewarding career with one of the most respected healthcare organizations in the world.     

As an UM Reviewer RN, you will perform various Utilization Management related activities, including admission, concurrent, retrospective chart and clinical systems reviews to measure clinical performance and issues that affect reimbursement for the medical care. Some of your other daily responsibilities may be providing clinical information to the payer, UM data collection and reporting, concurrent denials appeals process and special projects as assigned. This position offers a unique way to make a difference in the lives of patients every day, all while enhancing your analytical and critical-thinking skills. 

A caregiver in this position works days from 8:00AM – 5:00PM.  

A caregiver who excels in this role will:  

• Recommend resource utilization. 
• Utilize analytical ability required to gather data.  
• Use clinical judgment to apply predetermined criteria or use independent clinical judgment when no predetermined criteria exist to identify problems, facilitate resolution, recommend corrective action, and report results effectively. 
• Use independent clinical judgment in reviewing records to determine status of patients stay, if proper procedures have been followed, seriousness of incidents and ability to identify need for and participate in focused reviews, special projects and identify opportunities for improvement. 
• Make recommendations regarding appropriateness of the treatment plan for continued stay and safety of the discharge plan. 
• Achieve a minimum of 85% on IRR quarterly. 
• Complete Utilization Management for assigned patients with a minimum of 25-30 reviews per day. 
• Apply medical necessity guidelines accurately to monitor appropriateness of admission and continued stays. 
• Follow department guidelines on escalation processes and refer cases appropriately to the internal or external PA. 
• Maintain professional work standards including confidentiality, ethical principles, and professional work habits. 
• Maintain and support collaborative relationships with TCC's, physicians and the multidisciplinary team. 
• Document appropriately in UM notes to provide evidence that the UR process for the case was followed. 
• Design and initiate special projects as supervised by the Team Manager. 

Minimum qualifications for the ideal future caregiver include:  

• Graduate from an accredited school of professional Nursing 
• Current state licensure as a Registered Nurse (RN) 
• Basic Life Support (BLS) Certification through the American Heart Association (AHA) 
• Three years of full-time clinical RN experience  
• Knowledge of medical terminology, anatomy, physiology, diagnosis, surgical procedures and basic disease processes 
• Analytical ability to gather data, decide on conformity based on predetermined criteria, identify problems and refer for resolution 
• Knowledge of medical records coding standards, licensing and accreditation standards, billing practices and problems, documentation and research 
• Knowledge and experience with care guidelines, medical necessity criteria and/or other UM criteria sets 
• Ability to assess medical records and make determinations on length of stay and proper procedures 
• Proficiency with Microsoft Office 

Preferred qualifications for the ideal future caregiver include: 

• Bachelor’s of Science in Nursing (BSN) 
• Case Management Certification (CCM)   
• UM experience 

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