Utilization Management Specialist NE
Cleveland Clinic
Utilization Management Specialist NE
Cleveland Clinic
Non-profit medical center delivering care
Join our team at Cleveland Clinic Indian RiverHospital andexperience world-class healthcare at its best. Cleveland Clinic Indian River has been recognized as one of the top regional hospitals in South Florida. Indian River Hospital is in sunny Florida’s Treasure Coast where it is committed to providingoptimalfamily-centric and community-focused care. At Indian River Hospital, you will be part of a collaborative, compassionate, and innovative team of caregivers. You will work withstate-of-the-arttechnology and will build a rewarding career with one of the most respected healthcare organizations in the world.
UtilizationManagement (UM) Specialists perform UM activities, such as admission review, concurrent review, retrospective chartreviewand clinical systems review to measure clinical performance and UM issues that affect reimbursement for the patient’s hospital stay or visit. Your workimpactsthe denial rate, which in returnwouldimpactpatientsout of pocketexpenses. Here, you will have the opportunity to work with a dynamic team of like-minded individuals and have the chance to growyourskills into a supervisor role.
APRN caregiver in this positionworksvarying daysfrom 7:30AM – 4:30PM.
A caregiver who excels in this role will:
Recommend resourceutilization.
Prioritize and organize work to meet changing priorities.
Utilize analytical abilitiesrequiredto gather data.
Use clinical judgment to apply predetermined criteria or use independent clinical judgment when no predetermined criteria exist toidentifyproblems,facilitateresolution, recommend corrective action, and report results effectively.
Use independent clinical judgment in reviewing records todeterminestatus of patients stay, if proper procedures have been followed, seriousness of incidents and ability toidentifyneed for andparticipatein focused reviews, special projects andidentifyopportunities for improvement.
Make recommendationsregardingappropriatenessof the treatment plan for continued stay and safety of the discharge plan.
Achieve a minimum of 85% on IRR quarterly.
Completeutilizationmanagement for assigned patients with at least 25-30 reviews per day.
Apply medical necessity guidelines accurately tomonitorappropriateness of admission and continued stays.
Document appropriately in UM notes to provide evidence that the UR process for the case was followed.
Minimum qualifications for the ideal future caregiver include:
Graduate from an accredited school of professional nursing (Diploma,ADNor BSN program)
Current state licensure as a Registered Nurse (RN)
Basic Life Support (BLS) certification through the American Heart Association (AHA)or American Red Cross
Threeyears ofequivalent full-time clinical experience as a Registered Nurse
Knowledge of medical terminology, anatomy, physiology, diagnosis, surgicalproceduresand basic disease processes
Analytical ability to gather data, decide on conformity based on predetermined criteria,identifyproblems and refer for resolution
Basic knowledge of medical record coding standards
Awareness of licensing and accreditation standards
Proficient with Microsoft Office
Knowledge of billing practices, identification of billing problems, adequacy of documentation, and ability to conduct research of issue at hand, as well as formulate recommendations based on findings
Knowledge and experience with Care Guidelines, Medical Necessity Criteria and/or other UM criteria sets
Advanced interpersonal and communication written and verbal skills
Ability toassess medical records anddeterminestay length and proper proceduresin accordance withpolicies and procedures
Demonstrated competence in all areasidentifiedin the Competencies, Dimensions, ProblemSolvingand Information Management sections
Cognizant of reimbursement denials and effect on cost of care
Knowledge of and ability to use multiple Hospital information systems and Department's software
Preferred qualifications for the ideal future caregiver include:
Bachelor ofScience inNursing (BSN)
Case Management Certification (CCM)within first year of eligibility
Prior Utilization Management experience
Physical Requirements:
Personal Protective Equipment:
The policy of Cleveland Clinic Health System and its system hospitals (Cleveland Clinic Health System) is to provide equal opportunity to all of our caregivers and applicants for employment in our drug free environment. All offers of employment are followed by testing for controlled substances.
Cleveland Clinic Health System administers an influenza prevention program. You will be required to comply with this program, which will include obtaining an influenza vaccination on an annual basis or obtaining an approved exemption.
Decisions concerning employment, transfers and promotions are made upon the basis of the best qualified candidate without regard to color, race, religion, national origin, age, sex, sexual orientation, marital status, ancestry, status as a disabled or Vietnam era veteran or any other characteristic protected by law. Information provided on this application may be shared with any Cleveland Clinic Health System facility.
If applying for a Florida position, please see the following website for more information on the background screening requirements required by the Agency of Health Care Administration: https://info.flclearinghouse.com/
Please review the Equal Employment Opportunity poster.
Cleveland Clinic is pleased to be an equal employment opportunity employer.
Non-profit medical center delivering care
Cleveland Clinic runs a nonprofit academic medical center that delivers patient care, conducts research, and educates future clinicians. It provides in-person hospital services, surgeries, and telehealth options, plus digital tools like MyChart to manage care, as well as provider tools such as DrConnect and eRadiology to coordinate care. It differentiates itself by combining clinical care, medical research, and education under a nonprofit model with a broad international network and a strong emphasis on safety and quality. Its goal is to deliver high-quality medical care while advancing medical knowledge and training clinicians to improve health outcomes for diverse populations, globally.
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