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Clinical Utilization Review Nurse

2 months ago

Michigan, United States EPITEC Full time

Position Overview:

The Utilization Management (UM) Program is designed with a focus on providers, necessitating professional collaboration with clinical personnel from Acute Inpatient Hospitals and Post-Acute Care facilities, as well as physicians. This role does not involve direct interaction with members or patients.

Objective:

The primary aim of the UM Program is to ascertain that members are placed in the most suitable environment, taking into account the severity of their medical condition and the intensity of services rendered during their inpatient stay.

Key Responsibilities:

  • Conduct thorough reviews of clinical documentation submitted by healthcare facilities.
  • Apply InterQual criteria effectively to assess patient needs.
  • Engage in professional communication (written, telephonic, and verbal) with clinical staff both internally and externally.

Qualifications:

  • A minimum of 2 years of experience in acute care, holding an unrestricted Registered Nurse license in Michigan.
  • Experience in ICU or ER settings is preferred; candidates should not solely have experience in specialized areas such as NICU, OB, BH, or Substance Abuse.
  • Familiarity with InterQual, MCG, or other utilization review methodologies.
  • Proficient computer skills are essential.
  • Typing speed of 40+ words per minute is required.
  • Must be a resident of Michigan.