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Utilization Management RN Reviewer FT - Utilization Review

Company: Cleveland Clinic
Location: Stuart
Posted on: May 28, 2023

Job Description:

Utilization Management RN Reviewer FTJoin Cleveland Clinic's Martin North Hospital where research and surgery are advanced, technology is leading-edge, patient care is world-class, and caregivers are family. This downtown Stuart hospital provides top-quality patient care to the communities in and around Martin County on the beautiful Indian River. The caregivers at Martin North Hospital have made it not only an excellent medical facility, but also a home away from home.

As a Utilization Management (UM) RN Reviewer, you will work under the general supervision of the UM Team Manager to perform UM activities which include admission review, concurrent review, retrospective chart review and clinical systems review to measure clinical performance and UM issues that affect reimbursement for the patient's hospital stay or visit. Some of your responsibilities include medical record review, providing clinical information to the payer, UM data collection and reporting, concurrent denials appeals process, clinical team interaction, Physician Adviser interaction, and special project which are coordinated and directed by the Team Manager. As supervised by the Team Manager, you may also design and initiate special projects.

The ideal future caregiver is someone who:

* Has three years of experience working in a hospital.
* Has utilization review experience.
* Demonstrates strong critical thinking and problem-solving skills.
* Is an excellent communicator.

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.


* 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 quarterly.
* Completes 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 RN Case Manager, 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.


* Graduate of an accredited school of nursing with licensure as a Registered Nurse (RN) in the State.
* Bachelor of Science in Nursing preferred.



* Current valid license as a Registered Nurse (RN).
* Basic Life Support (BLS) through American Heart Association (AHA).
* Case Management Certification (CCM) preferred.

Complexity of Work:

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.

Keywords: Cleveland Clinic, Palm Beach , Utilization Management RN Reviewer FT - Utilization Review, Executive , Stuart, Florida

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