Utilization Management RN Reviewer

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

Utilization Management RN Reviewers perform UM activities including admission review, concurrent review, retrospective chart review and clinical systems review to measure clinical performance and UM issues that affect reimbursement for the patient's hospital stay or visit. Other responsibilities include medical record review, providing clinical information to the payer, UM data collection and reporting, concurrent denials appeals process, clinical team interaction, Physician Adviser interaction and special projects which are coordinated and directed by the UM Team Manager.

A caregiver in this position works 8:00AM – 5:00PM. This will be a work from home position after orientation.

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 of science in nursing (BSN)
• Case Management Certification (CCM) within first year of eligibility.
• Prior UM experience
  
  

Our caregivers continue to create the best outcomes for our patients across each of our facilities. Click the link and see how we’re dedicated to providing what matters most to you: https://jobs.clevelandclinic.org/benefits-2/

Physical Requirements

• Walking, sitting, and/or standing for long periods of time
• Constant attention to detail, reading of medical records, and meeting deadlines
• Works in an environment where there is some discomfort due to dust, noise, temperature
  
  

Personal Protective Equipment

• Follow standard precautions using personal protective equipment
  
  

Additional Job Requirements

• One weekend every four weeks
• Must attend orientation and training in person for four to six weeks
  
  

Salaries [which may be] shown on independent job search websites reflect various market averages and do not represent information obtained directly from The Cleveland Clinic. Because we value each individual candidate, we invite and encourage each candidate to discuss salary/hourly specifics during the application and hiring process.