Utilization Review Specialist RN

2 weeks ago


Bay City, Michigan, United States McLaren Health Care Full time
Job Title: Utilization Review Specialist Registered Nurse

Job Summary:

We are seeking a skilled Utilization Review Specialist Registered Nurse to join our team at McLaren Health Care. As a key member of our healthcare team, you will play a critical role in ensuring that hospital admissions are based on medical necessity and that reimbursement is accurate.

Responsibilities:

  • Conduct concurrent reviews of medical records to ensure that admission and continued stay criteria are met and documented.
  • Collaborate with the healthcare team to determine the appropriate hospital setting (inpatient vs. outpatient) based on medical necessity.
  • Work with case management to expedite patient discharge.
  • Maintain current knowledge of hospital utilization review processes and participate in the resolution of retrospective reimbursement issues.
  • Assist with monitoring the effectiveness of the utilization management program and identifying areas for process improvement.

Requirements:

  • Nursing degree from an accredited educational institution.
  • State of Michigan licensure as a Registered Nurse (RN).
  • Two years of recent clinical or utilization management experience.

Preferred Qualifications:

  • Bachelor's degree in nursing.
  • Three years of recent case management or utilization management experience.

Equal Opportunity Employer:

McLaren Health Care is an equal opportunity employer committed to providing employment opportunity without regard to an individual's race, color, age, religion, sex/pregnancy, sexual orientation, gender identity, national origin, disability, veteran status, genetic information, or any other status prohibited by applicable laws.



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