Medical Utilization Review Professional
4 days ago
At Detroit Medical Center, we are seeking a highly skilled Medical Utilization Review Professional to join our team. This is a full-time days position.
Job SummaryThe Medical Utilization Review Professional will be responsible for facilitating effective resource coordination to help patients achieve optimal health, access to care, and appropriate utilization of resources. The ideal candidate will have excellent communication and organizational skills, as well as the ability to work effectively in a fast-paced environment.
Key Responsibilities:- Balances clinical and financial requirements and resources in advocating for patient needs with judicious resource management
- Promotes prudent utilization of all resources (fiscal, human, environmental, equipment, and services) by evaluating resources available to the patient and balancing cost and quality to assure optimal clinical and financial outcomes
- Completes admission reviews for all payors and sends admission reviews for payors with an authorization process
- Completes concurrent reviews for all payors and sends concurrent reviews to payors with an authorization process
- Closes open cases on the incomplete UM Census
- Completes the Medicare Certification Checklist on applicable admissions
- Discusses with the attending status changes, order clarifications, observation to inpatient changes for all payors
- Reviews the OR, IR, and cath lab schedule with follow-up as indicated
- Identifies and documents Avoidable Days
- Coordinates clinical care (medical necessity, appropriateness of care and resource utilization for admission, continued stay, and discharge) compared to evidence-based practice, internal and external requirements
- Provides denial information for UR Committee, Denial, and Revenue Cycle
- Collaborates with Patient Access, Case Management, Managed Care, and Business Office to improve concurrent review process to avoid denial or process delays in billing accounts
We offer a competitive salary range of $68,000 - $85,000 per year, based on experience, plus benefits including medical, dental, vision, employee assistance programs, life insurance, and a discount program.
Requirements- RN license required
- 2+ years of experience in utilization review or case management
- Excellent communication and organizational skills
- Ability to work effectively in a fast-paced environment
- Knowledge of medical terminology and coding systems
- Familiarity with hospital policies and procedures
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