Spectrum Health Utilization Review Specialist RN in Grand Rapids, Michigan
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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.
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
LIC-Registered Nurse (RN) - STATE_MI State of Michigan
SITE - Priority Health - 1231 E Beltline - Grand Rapids
PH - Pre-Service Utilization Management
Day (United States of America)
Weekly Scheduled Hours
Hours of Work
8:30 a.m. - 5:00 p.m.
Monday - Friday
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Who We Are
Spectrum Health is a nationally recognized not-for-profit health system, offering a full continuum of health services through our health plan, medical group and hospital group. As an integrated health system, we are able to work together across all facilities, employees and providers to create exceptional, consumer-focused interactions.
Spectrum Health is redefining what it takes to improve the health of our communities and introducing new and innovative ways for consumers to access high-quality, low-cost care so that they can connect with us for a lifetime of health.
We strive to provide one Spectrum Health experience: a consistent, high-quality, seamless health journey for consumers; no matter where, when or how they interact with us. The result is better health outcomes for the thousands of individuals, families and communities we serve.
We are the region’s largest employer, with corporate offices located in Grand Rapids, Michigan. Spectrum Health Hospital Group and Spectrum Health Medical Group are consistently recognized for the exceptional care they provide. Priority Health is among the largest health system-sponsored health plans in the U.S. and offers extensive experience serving large and small employer groups, individuals, Medicare Advantage, Healthy Michigan Plan and Medicaid populations.
Since 2010, Spectrum Health has been listed five times among the 15 Top Health Systems in the U.S. by Truven Analytics™. Click here (https://www.spectrumhealth.org/about-us/quality-safety-and-patient-experience/awards) to see a complete list of our safety, quality and patient experience awards.