Utilization Management RN Reviewer

🔥 4 minutes ago

🐊 Florida, Nevada, +1 more states – Remote

🐊 Florida – Remote 🎰 Nevada – Remote 🏈 Ohio – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

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👻 Ghost score 10%

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Cleveland Clinic

WebsiteLinkedInAll Job Openings

10,000+ employees

🏥 Healthcare

⚕️ Healthcare Insurance

🧘 Wellness

Healthcare • Healthcare Insurance • Wellness

Cleveland Clinic is a not-for-profit, multispecialty academic medical center located in Cleveland, Ohio. Founded in 1921, it integrates clinical and hospital care with research and education, earning a reputation as one of the largest and most respected hospitals in the country. The health system includes multiple facilities across Northeast Ohio and other locations globally, providing a wide range of specialized services such as cancer care, women's health, dermatology, and cardiovascular care. Cleveland Clinic is accredited by The Joint Commission, which underscores its commitment to high standards in healthcare delivery.

📋 Description

• Perform admission review, concurrent review, retrospective chart review, and clinical systems review • Measure clinical performance and utilization management issues affecting reimbursement • Review medical records and provide clinical information to payers • Collect and report utilization management data • Participate in concurrent denials appeals processes • Interact with clinical teams and Physician Advisers • Participate in special projects and focused reviews • Recommend resource utilization • Apply clinical judgment and predetermined criteria to identify problems and facilitate resolution • Determine patient stay status, appropriateness of treatment plans, continued stay, and discharge-plan safety • Recommend corrective actions and report results • Complete utilization management for assigned patients, conducting at least 25–30 reviews per day • Achieve a minimum quarterly IRR score of 85% • Apply medical necessity guidelines to monitor admissions and continued stays • Document UM notes demonstrating that the UR process was followed • Attend scheduled staff meetings • Perform other duties as assigned • Work remotely from 7:30 a.m.–4:00 p.m. with weekend requirements

🎯 Requirements

• Graduate of an accredited school of nursing • Current state licensure as a Registered Nurse (RN) • Basic Life Support (BLS) certification through the American Heart Association (AHA) or American Red Cross • Three years of equivalent full-time clinical experience as a Registered Nurse • Knowledge of medical terminology, anatomy and physiology, diagnosis, surgical procedures, and basic disease processes • Analytical ability to gather data and identify problems • Basic knowledge of medical records coding standards • Awareness of licensing and accreditation standards • Proficient with Microsoft Office • Knowledge of billing practices, billing problems, documentation adequacy, research, and formulating recommendations • Knowledge and experience with Care Guidelines, Medical Necessity Criteria and/or other UM criteria sets • Ability to assess medical records and determine length of stay and proper procedures • Knowledge of and ability to use multiple hospital information systems and department software • Ability to use a copier, fax machine, and personal computer • Preferred: Bachelor of Science in Nursing (BSN) • Case Management Certification (CCM) preferred within first year of eligibility • Preferred: prior Utilization Management experience • Preferred: case management or ED experience • Preferred: emergency room experience • Must comply with annual influenza vaccination or obtain an approved exemption • Must complete post-offer controlled-substance testing

🏖️ Benefits

• Remote work from 7:30 a.m.–4:00 p.m. • Full-time employment • Support and appreciation from Cleveland Clinic • Rewarding career with Cleveland Clinic Health System • Annual influenza vaccination or approved exemption program • Drug-free workplace with post-offer controlled-substance testing