Utilization Management Specialist NE

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