RN Utilization Management
Listed on 2026-09-18
-
Nursing
Healthcare Nursing, RN Nurse
Job Title
RN Utilization Management
Employment TypeFull-Time, 4:00pm-12:30am
OverviewSumma Health System is recognized as one of the region’s top employers by a number of third party organizations, including North Coast 99. Exceptional candidates gravitate to Summa because of its culture, passion for delivering excellent service to our patients and families commitment to our philosophy of servant leadership, collegial working relationships at every level of the organization and competitive pay and benefits.
SummaryManages appropriate cost-effective utilization of services across the care continuum to align with improved clinical outcomes and lower costs. Demonstrates responsiveness to changing health care needs of the patient population and changes in insurance contracts and payment modalities such as bundled payments and shared risk arrangements. Performs initial and concurrent clinical reviews on all the contracted and emergent non-contracted patient encounters to capture authorization for acute care provided.
Collaborates with Transitional Care Team, Physician Advisors, Providers and department leadership to effectively manage patient status (inpatient vs. observation) in the acute hospital setting per federal and payer guidelines through application of clinical criteria sets (MCG/Inter Qual) and compliance to federal guidelines (Medicare Two Midnight Rule). Supports Medicare patient right to appeal discharge in collaboration with QIO and Transitional Care team.
Support appeal of payer denials through engagement of internal Physician Advisor, contracted physician advising service (Optum) and collaboration with formal denial appeal RN team.
Education Required:
- Associate’s degree in Nursing (ADN) required, BSN preferred
- Graduate of a program of professional nursing that is accredited by the Commission on Collegiate Nursing Education (CCNE) or Accreditation Commission for Education in Nursing (ACEN)
- Current license to practice registered nursing in the State of Ohio
Required:
- Minimum of 2 years varied clinical experience in an acute care facility or having related experience in the Managed Health Care industry.
- Broad understanding of Utilization Management concepts that include, but are not limited to:
Traditional Medicare and Medicaid Regulations and Requirements, Medicare Two Midnight Rule, Condition Code 44, Condition Code W2, Important Message From Medicare, HINN 12 Letters, Medicare Inpatient only Procedure List;
Knowledge of Payer Types, Worker’s Compensation, Veteran’s Administration, DRG reimbursement, Outlier reimbursement agreements, Commercial insurance plan types: PPO, POS, HMO, Medicare Open Plans, Marketplace Plans, Carve out for Services, Indigent Plans, Institutional Accounts, ICD-10 codes.
Qualifications:
- Demonstrate ability to communicate clearly, professionally, and confidentially
- Ability to analyze and use clinical outcome and aggregate data
- Demonstrate clinical expertise in patient population
- Ability to work independently to prioritize work and solve problems
- Population Specific
Competency:
Ability to effectively interact with populations of patients/customers with an understanding of their needs for self-respect and dignity - Broad understanding of insurance industry
- Sedentary:
Exerts up to ten pounds of force occasionally and/or a negligible amount of force frequently.
Equal Opportunity Employer/Veterans/Disabled
Salary$37.40/hr - $56.11/hr
Salary DetailsThe salary range on this job posting/advertising is base salary exclusive of any bonuses or differentials. Many factors, such as years of relevant experience and geographical location are considered…
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