About Us
McLaren Health Care is a fully integrated health network committed to quality, evidence-based patient care with locations in Michigan and Indiana. The McLaren system includes 13 hospitals in Michigan, ambulatory surgery centers, imaging centers, a primary and specialty care physician network, commercial and Medicaid HMOs, home health, infusion and hospice providers, pharmacy services, a clinical laboratory network and a wholly owned medical malpractice insurance company. McLaren operates Michigan’s largest network of cancer centers and providers, anchored by the Karmanos Cancer Institute, one of only 53 National Cancer Institute-designated comprehensive cancer centers in the U.S.
Registered Nurse - Utilization Management
Department: Utilization Management
Daily Work Times: 7:00am-3:30pm
Shift: Days
Scheduled Bi-Weekly Hours: 40
Position Summary: Responsible for determining the appropriate patient status based on the regulatory and reimbursement requirements of various commercial and government payers in collaboration with the admitting/attending physician. Partners with the health care team to ensure hospital admissions are based on medical necessity and documentation is sufficient to support the level of care being billed. Conducts concurrent reviews to ensure criteria for patient status 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 resolution.
Essential Functions and Responsibilities as Assigned:
1. 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 appropriate.
- Works collaboratively with ICM service lines to expedite patient discharge.
- Screens physician documentation or order entry for timeliness, appropriateness and completeness as pertains to the utilization management process including level of care, medical necessity, and third-party payer requirement.
5. Documents in the electronic medical record (EMR): clinical reviews (medical necessity), payer authorizations, avoidable days, readmission risks, continued stay reviews and potential discharge date. Utilizes other application tools to document including Veracity, Optum, InterQual, Milliman, etc.
- Facilitates peer to peer reviews with payer/providers.
- Actively participates in clinical case review/rounds with the interdisciplinary team regarding continued stays review/LOS outliers,
- Collaborate with providers/physician advisor when medical necessity and/or appropriateness of care is questioned, in accordance with established SOP procedures.
- 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.
10. 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.
Required:
- State licensure as a registered nurse (RN)
- Bachelor’s degree in nursing from accredited educational institution, or actively pursuing degree and to be obtained within five years of accepting position.
- Three years of recent nursing or utilization management experience with an acute care hospital
Preferred:
- Experience in utilization management/case management, critical care, clinical documentation, or patient outcomes/quality management.
- Certification in Case Management Certification (ACM or CCM)
- Basic Life Support (BLS) certification as a Healthcare Provider by the American Heart Association, American Red Cross or equivalent through the Military Training Network (MTN)
Equal Opportunity Employer
McLaren Health Care is an Equal Opportunity Employer. Qualified applicants will receive consideration for employment without regard to race, color, religion, sexual orientation, gender identification, age, sex, marital status, national origin, disability, genetic information, height or weight, protected veteran or other classification protected by law.
