RN Utilization Review Specialist

Our new name signals our bold commitment to health and wellness. At our core, we are here to help people be well so they can live their healthiest life possible. Through health care and health coverage, we create more value.​ Through compassion, collaboration, clarity, curiosity and courage, we make anything and everything possible.​ Through our people, we care for the whole person with respect, dignity and love. ​Everyone deserves opportunities and resources for better health.​ Everyone deserves our relentless pursuit to innovate and always do better. ​Everyone deserves to have a community be a great place to live, work, learn and play.​ We believe health and well-being should be within reach for all. We believe the system to support the entire health and wellness journey starts with prevention. ​We believe that together we will make a difference.​ Together, we are here to make health better for everyone.​ Together, we are Corewell Health.

Scope of work

Provides health information, interacts and acts as a resource for nursing units for complex clinical situations to ensure appropriate use of acute care services and diagnosis-related group (DRG) management. Assesses appropriateness of inpatient 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 and Medical Social Workers to move patients through the continuum appropriately.

• 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.
• Adjusts patient registration status code, as needed, to maximize reimbursement and be 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.

How we will care for you, while you care for our patients

• 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, pet insurance
• Traditional and Roth retirement options with service contribution and match savings
• Free onsite parking

Qualifications

• Required Associate's Degree Nursing
• Preferred Bachelor's Degree Nursing
• 2 years of relevant experience acute care, clinical nursing, preferably multiple clinical settings, or related experience Required
• Registered Nurse (RN) - State of Michigan License required