RN Coordinator-Utilization Review - Inpatient

RN Coordinator-Utilization Review - Inpatient - Full Time - 40 Hours - Days

Under minimal supervision, reviews and screens the appropriateness of services, the utilization of hospital resources and the quality of patient care rendered. Combines clinical, business, regulatory knowledge, and skill to reduce significant financial risk and exposure caused by concurrent and retrospective denial of payments for services provided. Through continuous assessments from admission through discharge, problem identification and education, facilitates the quality of health care delivery in the most cost effective and efficient manner.

Utilizes best practice workflows, evidence-based screening criteria and critical thinking to maximize reimbursement

PRINCIPLE DUTIES AND RESPONSIBILITIES:

1. Utilize the approved screening guidelines and strong understanding of disease processes to accurately determine severity of illness, intensity of service and medical necessity.

2. Evaluate the appropriateness of admission care and continuation of care.

3. Collaborates with providers and physician advisors regarding patient acuity and medical necessity for intensity of service.

4. Responds to pre-claim payor denials by facilitating peer-to-peer discussions to prevent post-bill denials.

5. Assesses readiness for discharge through continued stay review to evaluate medical necessity for continued hospital care.

6. Identify opportunities to improve progression in the transition of care through a safe discharge plan.

7. Serves as a liaison between Inpatient Case Management and payers, establishing relationships that positively impact financial outcomes.

8. Proactively identify issues throughout the hospitalization to improve the utilization of hospital resources.

9. Reviews and provides concise clinical information to Physician Advisor to ensure accurate information being provided to the corresponding governmental agencies and third-party payers.

10. Reviews and provides medical information for those patients whose financial reimbursement to the hospital is dependent upon information being provided to the appropriate government agencies and third-party payers.

11. Identifies inappropriate/inaccurate documentation that may potentially have legal and/or financial ramifications. Follows established guidelines for reporting issues.

12. Facilitate and coordinate involvement of medical staff, when appropriate, in responding to third party payers' requests to ensure positive outcomes and maximal reimbursement of hospital services.

EDUCATION/EXPERIENCE

REQUIRED:

• Minimum 3-5 years of clinical experience required.

• Bachelor of Science Nursing required OR four (4) years Case Management/ Appeal/Utilization Management experience in lieu of bachelor’s degree.

CERTIFICATIONS/LICENSURES

REQUIRED:

Registered Nurse with a valid, unrestricted State of Michigan License

Additional Information

• Organization:
  Corporate Services
• Shift: Day Job
• Union Code:
  Not Applicable

This posting represents the major duties, responsibilities, and authorities of this job, and is not intended to be a complete list of all tasks and functions. It should be understood, therefore, that incumbents may be asked to perform job-related duties beyond those explicitly described above.

Henry Ford Health partners with millions of people on their health journey, across Michigan and around the world. We offer a full continuum of services – from primary and preventative care to complex and specialty care, health insurance, a full suite of home health offerings, virtual care, pharmacy, eye care and other health care retail. With former Ascension southeast Michigan and Flint region locations now part of our team, Henry Ford’s care is available in 13 hospitals and hundreds of ambulatory care locations.

Based in Detroit, Henry Ford is one of the nation’s most respected academic medical centers and is leading the Future of Health:
Detroit, a $3 billion investment anchored by a reimagined Henry Ford academic healthcare campus. Learn more at  .

The health and overall well-being of our team members is our priority. That’s why we offer support in the various components of our team’s well-being: physical,…