Utilization Review Spec RN
Company: McLaren Northern Michigan
Location: Port Huron
Posted on: June 6, 2021
Dept: Case Management
Hours per pay period: Casual
In conjunction with the admitting/attending physician, the UR
Specialist RN assists in determining the appropriate admission
status based on the regulatory and reimbursement requirements of
various commercial and government payers. Partners with the health
care team to ensure reimbursement of hospital admissions is based
on medical necessity and documentation is sufficient to support the
level of care being billed. Conducts concurrent reviews as directed
in the hospitals UR Plan of medical records to ensure criteria for
admission and continued stay are met and documented. Along with
other health care team members, monitors the use of hospital
resources and identifies delays. Reports delays to leadership for
- Performs a variety of concurrent and retrospective utilization
management-related reviews and functions to ensure that appropriate
data are tracked, evaluated, and reported.
- Collaborates with the health care team to determine the
appropriate hospital setting (inpatient vs. outpatient) based on
medical necessity. Actively seeks additional clinical documentation
from the physician to optimize hospital reimbursement when
- Works collaboratively with case management to expedite patient
- Maintains current knowledge of hospital utilization review
processes and participates in the resolution of retrospective
reimbursement issues including appeals, PACER authorization, third
party payer certification, and denied cases.
- Assists with monitoring the effectiveness/outcomes of the
utilization management program, identifying and applying
appropriate metrics, evaluating the data, reporting results to
various audiences, and designing and implementing process
improvement projects as needed.
- Identifies, develops, and provides orientation, training, and
competency development for appropriate staff and colleagues on an
- Analyzes, updates, and modifies procedures and processes to
continually improve utilization review operations.
- Maintains professional and technical knowledge by attending
educational workshops; reviewing professional publications;
establishing personal networks; participating in professional
- Complies with federal, state, and local legal and certification
requirements by studying existing and new legislation; anticipating
future legislation; enforcing adherence to requirements; advising
management on needed actions.
- Performs other related duties as required and directed.
- Nursing degree from an accredited educational institution
- State of Michigan licensure as a Registered Nurse (RN)
- Two (2) years of recent clinical or utilization management
- Bachelors degree in nursing.
- Three (3) years of recent case management or utilization
Equal Opportunity Employer of
Keywords: McLaren Northern Michigan, Warren , Utilization Review Spec RN, Other , Port Huron, Michigan
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