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RN Utilization Management Specialist
4 months ago
Join the Cleveland Clinic team, where you will work alongside passionate caregivers and provide patient-first healthcare. Cleveland Clinic is recognized as one of the top hospitals in the nation. 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.As a Utilization Management (UM) Registered Nurse (RN) Reviewer NE PRN, you will play a vital role in assisting with authorizations for hospital stays, monitoring LOS and helping coordinate care with the Case Manager and providers to ensure the best patient outcomes. Under the general supervision of the UM Team Manager, you will perform UM activities, such as admission, concurrent and retrospective chart reviews, review medical records and UM data collection and reporting, interact with Physician Advisors, and design and initiate special projects directed by the UM Team Manager. This position is remote, but you may be required to attend staff meetings or training sessions in person when needed, but these meetings are currently being held remotely until further notice. There may also be assignments that include enterprise hospitals in the Cleveland enterprise.Orientation will require 4 weeks onsite training at our Independence location.The ideal future caregiver is someone who:Can multitask in a stressful situation. Works well in a close-knit, teambuilding environment. Has a Basic Life Support certification, a valid Registered Nurse licensure, and three years equivalent full-time clinical experience as an RN. Has knowledge of medical terminology, anatomy and physiology, diagnosis, surgical procedures, and basic disease processes. Has UM, EPIC, Careport, and MCG experience.Must live in Cleveland, OH AreaThis is an excellent opportunity for those who are flexible and would like to advance their career within Cleveland Clinic. Caregivers in this position will have the opportunity to learn and grow their skills such as becoming proficient in EPIC, MCG and Careport. There are also vertical growth opportunities to become Care Management certified.At Cleveland Clinic, we know what matters most. That's why we treat our caregivers as if they are our own family, and we are always creating ways to be there for you. Here, you'll find that we offer: resources to learn and grow, a fulfilling career for everyone, and comprehensive benefits that invest in your health, your physical and mental well-being and your future. When you join Cleveland Clinic, you'll be part of a supportive caregiver family that will be united in shared values and purpose to fulfill our promise of being the best place to receive care and the best place to work in healthcare.Responsibilities:Recommends resource utilization.Prioritizes and organizes work to meet changing priorities.Utilizes analytical ability required to gather data. Uses clinical judgment to apply predetermined criteria or uses independent clinical judgment when no predetermined criteria exists to identify problems, facilitate resolution, recommend corrective action, and report results effectively.Uses 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.Makes recommendations regarding appropriateness of the treatment plan for continued stay and safety of the discharge plan.Achieves a minimum of 85% on IRR pletes Utilization Management for assigned patients with a minimum of 25-30 reviews per day.Applies medical necessity guidelines accurately to monitor appropriateness of admission and continued stays.Follows department guidelines on escalation processes and refer cases appropriately to the internal or external PA.Maintains professional work standards including confidentiality, ethical principles, and professional work habits.Maintains and supports collaborative relationships with TCC's, Physicians and the multidisciplinary team.Documents appropriately in UM notes to provide evidence that the UR process for the case was followed.Attend all staff meeting when scheduled to work.Other duties as assigned.Education: Graduate of an accredited school of nursing with licensure as a Registered Nurse (RN) in the State of Ohio.Bachelor of Science in Nursing preferred.Certifications: Current valid license in the State of Ohio as a Registered Nurse (RN).Case Management Certification (CCM)preferred within first year of eligibility.Basic Life Support (BLS) through American Heart Association (AHA).Work Experience:Requires three years equivalent full-time clinical experience as a Registered Nurse.Prior Utilization Management experience is preferred.Knowledge of medical terminology, anatomy and physiology, diagnosis, surgical procedures, and basic disease processes.Analytical ability required to gather data, decide on conformity based on predetermined criteria, identify problems and refer for resolution.Basic knowledge of medical records coding standards.Awareness of licensing and accreditation standards.Proficient with Microsoft Office.Knowledge of billing practices, identification of billing problems, adequacy of documentation, and ability to conduct research of issue at hand, as well as formulate recommendations based on findings; capable of providing in-service education to health care providers in regard to this topic.Knowledge and experience with Care Guidelines, Medical Necessity Criteria and/or other UM criteria sets.Must possess advanced interpersonal and communication written and verbal skills necessary to gather and exchange data (both internally and externally) with members of the health care team.Ability to assess medical records and make determinations on length of stay and proper procedures in accordance with policies and procedures, with experience in assigned specialty.Demonstrated competence in all areas identified in the Competencies, Dimensions, Problem solving, and Information Management sections Participates in departmental cost containment; cognizant of reimbursement denials and effect on cost of care.Knowledge of and ability to use multiple Hospital information systems and Department's software; report and follow-up on software problems resulting in delay in work flow.Ability to use copier, fax machine and personal computer and knowledge of Microsoft Office.Physical Requirements: Requires walking, sitting, and/or standing for long periods of time.Requires 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: Follows standard precautions using personal protective equipment.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.
