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Form of workIn conjunction with the admitting/attending physician, the UR Specialist RN assists in determining the appropriate admission status based on the regulatory and reimbursement requirements of various commercial and government payers. Partners with the health care team to ensure reimbursement of hospital admissions is based on medical necessity and documentation is sufficient to support the level of care being billed. Conducts concurrent reviews as directed in the hospital's UR Plan of medical records to ensure criteria for admission and continued stay are met and documented.
Along with other health care team members, monitors the use of hospital resources and identifies delays. Reports delays to leadership for resolution.ESSENTIAL FUNCTIONS AND RESPONSIBILITIES* Performs a variety of concurrent and retrospective utilization management-related reviews and functions to ensure that appropriate data are tracked, evaluated, and reported.* Collaborates with the health care team to determine the appropriate hospital setting (inpatient vs. outpatient) based on medical necessity.
Actively seeks additional clinical documentation from the physician to optimize hospital reimbursement when appropriate.* Works collaboratively with case management to expedite patient discharge.* Maintains current knowledge of hospital Utilization Review processes and participates in the resolution of retrospective reimbursement issues including appeals, PACER authorization, third party payer certification, and denied cases.* Assists with monitoring the effectiveness/outcomes of the utilization management program, identifying and applying appropriate metrics, evaluating the data, reporting results to various audiences, and designing and implementing process improvement projects as needed.* Identifies, develops, and provides orientation, training, and competency development for appropriate staff and colleagues on an ongoing basis.* Analyzes, updates, and modifies procedures and processes to continually improve Utilization Review operations.* Maintains professional and technical knowledge by attending educational workshops; reviewing professional publications; establishing personal networks; participating in professional societies.* Complies with federal, state, and local legal and certification requirements by studying existing and new legislation; anticipating future legislation; enforcing adherence to requirements; advising management on needed actions.* Performs other related duties as required and directed.QUALIFICATIONS REQUIRED* Nursing degree from an accredited educational institution* State of Michigan licensure as a Registered Nurse (RN)* Two years of recent clinical or utilization management experienceQUALIFICATIONS PREFERRED* Bachelor's degree in nursing.* Three years of recent case management or utilization management experienceKNOWLEDGE SKILLS AND ABILITLIES* Demonstrated expertise in utilization management principles, methods, and tools and incorporating them into the daily operations of the organization.* Ability to understand, interpret, explain, and use data for utilization management activities.* Competency in applying the principles, methods, materials, and equipment necessary in providing utilization management services.* Demonstrated clinical expertise to effectively facilitate evaluation of level of care required.* Expertise in developing and maintaining strong, collaborative, and supportive working relationships with peers, physicians, and other clinical professionals. Effective and efficient collaboration with others as a "team player".* Ability to effectively provide and receive feedback, both positive and constructive.* Ability to understand, interpret, explain, and use data for utilization management activities.* Well-developed written, verbal, and presentation skills.* Knowledge of care delivery systems across the continuum of care including, but not limited to, trends and issues in care reimbursement, scope of alternate site care, and available community resources.* Mid to high level proficiency with Microsoft Office applications.* Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists.* Compliance with the Code of Ethics and Guide for Professional Conduct.SUBSIDIARY SPECIFIC EXPECTATIONS* Responsible to facilitate daily bed control meeting.* Safeguards and maintains confidentiality of all patient, medical staff and employee information.* Assigns patients to clinically appropriate beds. When appropriate bed is not available then arranges for the best alternative for the patient.* Communicates with appropriate management staff to apprise him/her of the current bed status, identifying potential problems.* Assigns all beds, including in-house transfers, ED admissions and transfers from other hospitals.Additional Information* Schedule: Full-time* Requisition ID: 23005022* Daily Work Times: 8a-430p* Hours Per Pay Period: 80* On Call: No* Weekends: NoPer Centers for Medicare & Medicaid Services (CMS) regulations, all McLaren employees must be vaccinated for COVID-19 by January 4, 2022.
The regulation permits exemptions for employees with qualified medical disabilities or religious beliefs.Equal Opportunity EmployerMcLaren Health Care is an Equal Opportunity Employer. Qualified applicants will receive consideration for employment without regard to race, color, religion, sexual orientation, gender identification, age, sex, marital status, national origin, disability, genetic information, height or weight, protected veteran or other classification protected by law.
