Utilization Review Specialist; RN

Company Description

More Than Just Care,It’sCommunity

Imagine doing meaningful work in a place where people vacation.

That’slife at Munson Healthcare - northern Michigan’s largest healthcare system, with eight award-winning community hospitals serving over half a million residents across 29 counties.

If you want a career in healthcare and alifestylemost people only dream about – with freshwater lakes, scenic trails, charming downtowns, a vibrant arts scene, and endless outdoor adventures - you might just be Munson Material.

To us, that means teammates who live by our values of excellence,teamness, positivity, creativity,and a commitment to creating exceptional experiences for our patients and each other. Join a team that delivers outstanding care in one of the most beautiful regions in the country.

Invested in You

• Grow: Tuition reimbursement, in-person and online development,and access to ourcareer hubto help you advance.

• Thrive: Full benefits, paid holidays, generous PTO, employee discounts, and freeindividualretirement counseling.

• Be Well: Free wellness platform for you and your family,pluspersonalizedsupport for personal or family challenges.

• Be Heard: Share your ideas and help shape the way we work through improvement huddles, employee surveys, and town hall meetings

A Day In The Life

The Utilization Review Specialist (RN) is responsible for ensuring appropriate utilization of healthcare services across the continuum of care. This role evaluates patient admissions, continued stays, and transitions of care to ensure compliance with regulatory requirements, payer guidelines, and evidence-based standards of practice.

Working collaboratively with physicians, case managers, nursing staff, payers, and interdisciplinary teams, the Utilization Review Specialist promotes high-quality, cost-effective patient care while supporting optimal reimbursement and organizational performance. The position requires strong clinical judgment, critical thinking, communication skills, and knowledge of utilization management principles.

Admission

• Reviews available documentation to assess all admissions for appropriate status and services according to patient condition and diagnosis.
• Applies standard guidelines to determine appropriateness for inpatient level of care or observation services based on documented condition plan of treatment and care.
• Supports physician decision-making by coaching on appropriateness of inpatient or observation status.
• Confers with admitting physician if documentation does not support hospital level of care to offer alternatives.
• Refers cases to the Physician Advisor when documentation is inadequate to support acute level of care and remains unresolved after discussing with referring/attending physician.
• Understands and applies federal law regarding the use of Hospital Initiated Notice of Non-Coverage (HINN) and Ambulatory Benefit Notice (ABN).
• Monitors insurer compliance with contractual obligations.
• Maintains proficiency in the use of electronic review applications, including CERMe and EMR, and enters information correctly, consistently and timely.
• Maintains proficiency in the use of hospital information systems to access information and record data.

Continuing Stay

• Actively participate in daily huddles, patient care conferences, and hospitalist/nurses hand-off reports to maintain knowledge about the patient’s clinical status and progression of care.
• Consults with case manager and/or physician advisor as necessary to resolve progression-of-care barriers through appropriate administrative and medical channels.
• Identify potentially unnecessary services and care delivery settings and recommend alternatives when appropriate.
• Collaborates with community physicians and hospitalists to influence transition from one level of care to another.
• Notifies insurers and third party administrators of clinical review information.
• Maintains documentation on each patient to include specific criteria that support appropriate level of care and continued stay. Performs status changes as necessary
• Refers cases to the Physician Advisor when treatment plan documentation does not support acute level…