Beaumont Health System Utilization Mgmt Coord in Dearborn, Michigan
divGENERAL SUMMARY: This role includes accountability for utilization review (UR) and may include admission, concurrent, and retrospective reviews. Coordinates activities involved in the certification, recertification, and concurrent appeals process, conducting referrals for 2supnd/sup level review, as needed. Ensures timely communication with payers based on adequate and complete documentation received by the physicianrovider and utilization reviews. Initiates concurrent appeals to address patient class/status downgrades or clinical denials related to medical necessity.ESSENTIAL DUTIES:1. Participates within the department to meet expected objectives and outcomes.2. Meets or exceeds expectations related to behavior and performance. Meets individual and departmental objectives established for Quality, Satisfaction, Growth and Financial Success.3. Conducts timely and accurate utilization reviews, as assigned, using organization-approved UR criteria.4. Works closely with physician advisors and medical staff to ensure appropriate level of care, including obtaining physician orders for patient class changes when needed.5. Refers cases, as defined, for 2supnd/sup level medical necessity review.6. Maintains daily contact with payers to obtain authorization and reauthorization information and addresses concurrent denials and/or audit requests.7. Provides UR and clinical documentation is adequate and complies with payer requirements.8. Schedules next review/follow-up reviews as required in accordance with organizational policy and procedure and payer requests.9. Routinely collaborates with the System Clinical Appeals and Revenue Cycle departments to expedite billing and appeals processes.10. Maintains and monitors assigned workques within the Electronic Medical RecordSTANDARD QUALIFICATIONSA. uEducation / Training/u:College Level DegreeB. uWork Experience/u: u/uHospital utilization review/utilization management experience preferred; Clinical appeals experience desired. 2 years of experience in clinical/hospital setting.C. uCertification, Licensure, Registration/u: u/uLicensed as a Registered Nurse (RN) with Bachelors degree in nursing or other related field preferred.u/uD. uOther Qualifications/u:Outstanding organizational and communication skills (written and oral). Computer literate and adept. Impeccable customer service skills.div/div/divBeaumont Health is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, sex, gender identity, sexual orientation, age, status as a protected veteran, or status as a qualified individual with a disability.