Clinical Nurse Specialist in Utilization Management

1 week ago


Port Huron, Michigan, United States McLaren Health Care Full time
Position Overview:

The Clinical Nurse Specialist in Utilization Management plays a crucial role in assessing patient status in accordance with the regulatory and reimbursement guidelines set forth by various payers. This position collaborates closely with physicians and the healthcare team to ensure that hospital admissions are justified based on medical necessity and that all documentation is accurate and complete.

Key Responsibilities:
  • Conduct utilization management assessments and reviews
  • Work in partnership with the healthcare team to determine the most suitable hospital environment for patient care
  • Accurately document clinical evaluations and findings in the Electronic Medical Record (EMR)
  • Facilitate peer-to-peer discussions with payers and healthcare providers
  • Engage in clinical case evaluations with the multidisciplinary team
  • Stay informed about current utilization review protocols
  • Evaluate the effectiveness and outcomes of the utilization management initiatives
  • Support the orientation, training, and skill development of new staff
  • Carry out additional related responsibilities as needed
Qualifications:Mandatory:
  • Valid state licensure as a Registered Nurse (RN)
  • Bachelor's degree in Nursing
  • A minimum of three years of recent experience in nursing or utilization management
Desirable:
  • Experience in utilization management or case management
  • Certification in Case Management (ACM or CCM)
  • Basic Life Support (BLS) certification


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