Kettering Health Network

  • RN Utilization Rvw Spclst - Full Time - Varied Shifts

    Posted Date 5 days ago(8/10/2018 9:21 AM)
    Job ID
    2018-12851
    Job Category
    Nursing
    Job Type
    Full-Time
    Shift
    Varied Shifts
    # of Openings
    1
    Shift Time
    Varied (ex: Resource)
  • Overview

    Do you have clinical experience and are ready to take your career to the next level? Are you ready to participate in a fast paced Network setting? Join our Utilization Management team!  Varied shifts available.

     

    Responsibilities & Requirements

     Responsibilities:

     

     

    • Registered professional nurse with education, knowledge and experience.
    • Role focuses on review of inpatient and observation admissions to ensure correct assignment of Admit status.  Communicates concurrently and resolves medical necessity discrepancies with physicians and other hospital leadership as needed.
    • Responsible for completing clinical review on all assigned patients and communicates these reviews to payers.
    • Identifies potential or actual denials for admission or ongoing stay both during the patient’s hospital stay and post discharge.
    • Review and decide the validity of medical necessity payer denials.  Submits payer denial appeals.
    • Participates in design of work flows and procedure to reduce incidence of denials.

     Requirements:

     

     

    • Current unrestricted Ohio RN licensure, BSN required.

     

     

     

     

    Preferred Qualifications

     

    • 5 years clinical experience with 2 years case management preferred
    • Case Management certification preferred
    • Works independently
    • Familiar with MCG Care guidelines
    • Ability to adapt quickly to changing priorities and regulations
    • Experience with computers required.  Experience with Microsoft applications and EPIC software preferred

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