RN Utilization Review Specialist Priority Health

Scope of work:

Provides health information, interacts, and acts as a resource for providers for complex clinical situations to ensure appropriate use of preservice and concurrent acute medical and/or behavioral health care services. Assesses appropriateness of preservice and concurrent requests for admissions and continued stay. Educates medical staff/other health care professionals regarding utilization management and quality requirements. Makes recommendations and provides financial and utilization management (UM) information to other members of the care facilitation teams for work prioritization. Works closely with inpatient care facilitators, Medical Social Workers, home health agencies, and providers to move patients through the continuum appropriately. Medical necessity reviews for designated services are completed for all Priority Health plans.

• Assesses and interprets clinical information and assists in case management of complex patient population, through use of independent judgment, mature problem solving skills, and guidelines for appropriateness of acute care setting upon admission and continued stay.
• Ensure documentation and processes are consistent with regulatory standards
• Communicates with physicians, medical social workers, and other hospital personnel concerning change in level of care on the medically complex patient population. Makes recommendations and discusses alternatives. Provides financial/DRG, UM, health information to other facilitation team members for work prioritization. Communicates and collaborates with physicians and members of the team to ensure continuity and coordination of services.
• Documents any instances where services were delayed, inappropriate, refused, complicated, etc. for resource management functions.
• Identifies quality indicators to facilitate process improvement and physician education.
• Ensure members are authorized for the most appropriate level of care and services based on internal and external guidelines.
• Collaborates with Medical Directors

Qualifications

• Required Bachelor's Degree or equivalent Nursing or a health care related field;

• 2 years of relevant experience acute care, clinical nursing, preferably multiple clinical settings, or related experience Required
• 5 years of relevant experience Skills/knowledge/abilities typically gained through at least five years, post licensure, related experience in acute care, multiple clinical settings or behavioral health with utilization management ,discharge planning designing patient centered care plan or related work Required

• Registered Nurse (RN) - State of Michigan Upon Hire required

How Corewell Health cares for you

• Comprehensive benefits package to meet your financial, health, and work/life balance goals. Learn more here.
• On-demand pay program powered by Payactiv
• Discounts directory with deals on the things that matter to you, like restaurants, phone plans, spas, and more!
• Optional identity theft protection, home and auto insurance
• Traditional and Roth retirement options with service contribution and match savings
• Eligibility for benefits is determined by employment type and status

Primary Location

SITE - Priority Health - 1231 E Beltline Ave NE - Grand Rapids

Department Name

Utilization Management - PH Managed Benefits

Employment Type

Full time

Shift

Day (United States of America)

Weekly Scheduled Hours

40

Hours of Work

8:00 a.m. to 5:00 p.m.

Days Worked

Monday to Friday

Weekend Frequency

N/A

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Corewell Health is committed to providing a safe environment for our team members, patients, visitors, and community. We require a drug-free workplace and require team members to comply with the MMR, Varicella, Tdap, and Influenza vaccine requirement if in an on-site or hybrid workplace category. We are committed to supporting prospective team members who require reasonable accommodations to participate in the job application process, to perform the essential functions of a job, or to enjoy equal benefits and privileges of employment due to a disability, pregnancy, or sincerely held religious belief.

Corewell Health grants equal employment opportunity to all qualified persons without regard to race, color, national origin, sex, disability, age, religion, genetic information, marital status, height, weight, gender, pregnancy, sexual orientation, gender identity or expression, veteran status, or any other legally protected category.

An interconnected, collaborative culture where all are encouraged to bring their whole selves to work, is vital to the health of our organization. As a health system, we advocate for equity as we care for our patients, our communities, and each other. From workshops that develop cultural intelligence, to our inclusion resource groups for people to find community and empowerment at work, we are dedicated to ongoing resources that advance our values of diversity, equity, and inclusion in all that we do. We invite those that share in our commitment to join our team.

You may request assistance in completing the application process by calling 616.486.7447.