Utilization Management Specialist - RN Registered Nurse at Cleveland Clinic

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About the position

Join Cleveland Clinic Weston Hospital's team of caregivers that remain on the leading edge of technology and education while consistently providing patient-centered healthcare. As part of Cleveland Clinic's Florida region, Weston Hospital is recognized as one of the top hospitals in the Miami-Fort Lauderdale metro area and Florida. Here, 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 (UM) Specialists perform UM activities, such as 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. Some of the responsibilities of a Utilization Management Specialist include medical record review, providing clinical information to payers, UM data collection and reporting, concurrent denials appeals process, clinical team interaction, Physician Adviser interaction, and special projects. Candidates for this role must have open availability to work 24-40 hours per week, including evenings and weekends. This position offers the flexibility of working from home and support in gaining your case management certification. Candidates must live within a reasonable distance of a Cleveland Clinic Florida location. A caregiver who excels in this role will recommend resource utilization, prioritize and organize work to meet changing priorities, utilize analytical abilities required to gather data, and 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. They will also make recommendations regarding the appropriateness of the treatment plan for continued stay and safety of the discharge plan, achieve a minimum of 85% on IRR quarterly, and complete utilization management for assigned patients with at least 25-30 reviews per day. Additionally, they will apply medical necessity guidelines accurately to monitor the appropriateness of admission and continued stays, and document appropriately in UM notes to provide evidence that the UR process for the case was followed.

Responsibilities

  • Perform admission review, concurrent review, retrospective chart review, and clinical systems review.
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  • Conduct medical record review and provide clinical information to payers.
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  • Collect and report UM data.
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  • Manage the concurrent denials appeals process.
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  • Interact with clinical teams and Physician Advisers.
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  • Complete special projects as assigned.
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  • Recommend resource utilization and prioritize work to meet changing priorities.
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  • Utilize analytical abilities to gather data and apply clinical judgment to identify problems and recommend corrective actions.
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  • Achieve a minimum of 85% on IRR quarterly.
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  • Complete utilization management for assigned patients with at least 25-30 reviews per day.
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  • Apply medical necessity guidelines to monitor appropriateness of admission and continued stays.
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  • Document appropriately in UM notes to evidence the UR process for the case.

Requirements

  • Graduate from an accredited school of professional nursing.
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  • Current state licensure as a Registered Nurse (RN).
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  • Basic Life Support (BLS) certification through the American Heart Association (AHA).
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  • Three to five years of full-time clinical experience as an RN.
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  • Knowledge of medical terminology, anatomy, physiology, diagnosis, surgical procedures, and basic disease processes.
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  • Analytical ability to gather data and decide on conformity based on predetermined criteria.
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  • Basic knowledge of medical record coding standards.
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  • Awareness of licensing and accreditation standards.
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  • Proficient with Microsoft Office.
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  • Knowledge of billing practices and ability to conduct research on issues at hand.

Nice-to-haves

  • Bachelor of science in nursing (BSN).
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  • Case Management Certification (CCM) preferred.
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  • Experience working as a hospital RN as well as UR or Case Manager.
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  • Flexible schedule to support department needs.
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  • Strong computer skills.

Benefits

  • Flexibility of working from home.
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  • Support in gaining case management certification.
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