RN Coordinator-Utilization Review - Observation -Full Time - 40 Hours - Days
🔍 Troy, Michigan
GENERAL SUMMARY:
Under minimal supervision, reviews and screens the appropriateness of services, the utilization of hospital resources and the quality of patient care rendered. Combines clinical, business, regulatory knowledge, and skill to reduce significant financial risk and exposure caused by concurrent and retrospective denial of payments for services provided. Through continuous assessments from admission through discharge, problem identification and education, facilitates the quality of health care delivery in the most cost effective and efficient manner. Utilizes best practice workflows, evidence-based screening criteria and critical thinking to maximize reimbursement
PRINCIPLE DUTIES AND RESPONSIBILITIES:
1. Utilize the approved screening guidelines and strong understanding of disease processes to accurately determine severity of illness, intensity of service and medical necessity.
2. Evaluate the appropriateness of admission care and continuation of care.
3. Collaborates with providers and physician advisors regarding patient acuity and medical necessity for intensity of service.
4. Responds to pre-claim payor denials by facilitating peer-to-peer discussions to prevent post-bill denials.
5. Assesses readiness for discharge through continued stay review to evaluate medical necessity for continued hospital care.
6. Identify opportunities to improve progression in the transition of care through a safe discharge plan.
7. Serves as a liaison between Inpatient Case Management and payers, establishing relationships that positively impact financial outcomes.
8. Proactively identify issues throughout the hospitalization to improve the utilization of hospital resources.
9. Reviews and provides concise clinical information to Physician Advisor to ensure accurate information being provided to the corresponding governmental agencies and third-party payers.
10.Reviews and provides medical information for those patients whose financial reimbursement to the hospital is dependent upon information being provided to the appropriate government agencies and third-party payers.
11.Identifies inappropriate/inaccurate documentation that may potentially have legal and/or financial ramifications. Follows established guidelines for reporting issues.
12.Facilitate and coordinate involvement of medical staff, when appropriate, in responding to third party payers' requests to ensure positive outcomes and maximal reimbursement of hospital services.
.EDUCATION/EXPERIENCE REQUIRED:
• Registered Nurse required.
• Minimum 3-5 years of clinical experience required.
• Bachelor of Science Nursing required OR four (4) years Case Management/ Appeal/Utilization Management experience in lieu of bachelor’s degree.
CERTIFICATIONS/LICENSURES REQUIRED:
Registered Nurse with a valid, unrestricted State of Michigan License
Overview
HAP is a Michigan-based, nonprofit health plan that provides health coverage to individuals, Â Â Â Â Â companies and organizations. A subsidiary of Henry Ford Health System, we partner with doctors, employers and community groups to enhance the overall health and well-being of the lives we touch. With more than 1,100 dedicated and passionate employees, our goal is to make health care easy for our members.
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Under the leadership of President and CEO Robert G. Riney, Henry Ford Health is a
$6 billion integrated health system comprised of six hospitals, a health plan, and 250+ sites
including medical centers, walk-in and urgent care clinics, pharmacy, eye care facilities and
other healthcare retail. Established in 1915 by auto industry pioneer Henry Ford, the health system
now has 32,000 employees and remains home to the 1,900-member Henry Ford Medical Group, one
of the nation’s oldest physician groups. An additional 2,200 physicians are also affiliated with the
health system through the Henry Ford Physician Network. Henry Ford is also one of the region’s Â
major academic medical centers, receiving between $90-$100 million in annual research funding and
remaining Michigan’s fourth largest NIH-funded institution. Also an active participant in medical
education and training, the health system has trained nearly 40% of physicians currently practicing
in the state and also provides education and training for other health professionals including nurses,
pharmacists, radiology and respiratory technicians. visit HenryFord.com.
Benefits
Whether it's offering a new medical option, helping you make healthier lifestyle choices or
making the employee enrollment selection experience easier, it's all about choice. Â Henry
Ford Health System has a new approach for its employee benefits program - My Choice
Rewards. Â My Choice Rewards is a program as diverse as the people it serves. Â There are
dozens of options for all of our employees including compensation, benefits, work/life balance
and learning - options that enhance your career and add value to your personal life. Â As an
employee you are provided access to Retirement Programs, an Employee Assistance Program
(Henry Ford Enhanced), Tuition Reimbursement, Paid Time Off, Employee Health and Wellness
and access to day care services at Bright Horizons Midtown Detroit, and a whole host of other
benefits and services. Employee's classified as contingent status are not eligible for benefits
Equal Employment Opportunity/Affirmative Action Employer
Equal Employment Opportunity / Affirmative Action Employer Henry Ford Health System is
committed to the hiring, advancement and fair treatment of all individuals without regard to
race, color, creed, religion, age, sex, national origin, disability, veteran status, size, height,
weight, marital status, family status, gender identity, sexual orientation, and genetic information,
or any other protected status in accordance with applicable federal and state laws.