RN Coordinator-Utilization Review Job Warren area,Michigan USA,Nursing

Position: RN Coordinator-Utilization Review - Full Time - 40 Hours - Days

RN Coordinator-Utilization Review - 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

Principal Duties and Responsibilities

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

Evaluate the appropriateness of admission care and continuation of care.

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

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

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

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

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

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

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

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.

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

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 / Licenses 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.

Equal Employment Opportunity / Affirmative Action Employer Henry Ford Health is committed to the hiring, advancement and fair treatment of all individuals without regard to race, color, creed, religion, age, sex, national origin, disability, veteran status, size, height, weight, marital status, family status, gender identity, sexual orientation, and genetic information, or any other protected status in accordance with applicable federal and state laws.

#J-18808-Ljbffr


Increase/decrease your Search Radius (miles)



Job Posting Language