RN Registered Nurse (Hybrid)- Utilization Review - 40 Hours Weekly - HAP Health Alliance Plan
🔍 Troy, Michigan
RN Registered Nurse - Utilization Review - 40 Hours Weekly - HAP Health Alliance Plan
Full Time Benefit Eligible
Schedule: Monday through Friday, 8:00AM to 4:30PM, Hybrid
GENERAL SUMMARY:
The Utilization Review (UR) Nurse ensures services meet member's health needs and promotes the provision of high quality care in the most appropriate and cost-effective setting by identifying, assessing, planning, coordinating, monitoring, and evaluating healthcare services, outcomes, and managing the utilization of Health Alliance Plan (HAP) benefits through activities of medical utilization review and discharge planning. This individual promotes collaboration with the patient care team, such as the Outpatient Case Management team, to ensure a high quality of patient care, reduced length of stay, efficient utilization of resources, and appropriate reimbursement of care and services, including discharge planning assistance and aftercare support. Time may be split between project work and performing clinical reviews.
EDUCATION/EXPERIENCE REQUIRED:
Nursing Diploma or equivalent. Bachelor of Science of nursing degree preferred. Four (4) years hospital clinical experience medical, surgical, orthopedic, neuro-surgery or pediatric nursing. Demonstrated knowledge of pathophysiology with application of critical thinking skills. HMO or managed care experience preferred. Two (2) years Utilization Management and/or Hospital discharge planning in the acute care setting within the past four (4) years preferred. Knowledge of Medicare, Medicaid and NCQA guidelines and use of CMS website for research preferred. Home Health Care experience preferred. Excellent verbal and written communication skills, including telephone etiquette and telephone skills for review. Typing skills. Knowledge of use of Microsoft Office Suite. Knowledge of ICD-9/ ICD-10 and CPT coding, medical necessity criteria and medical terminology.Broad-based knowledge of the physiologic, psychosocial, environmental, family, economic and religious dynamics that can affect members. Excellent organizational skills, including use of time management principles to accomplish priorities effectively. Work professionally with physicians and all disciplines and levels of staff. Ability to interpret and follow HAP, Medicaid, Medicare and Medical Management policy and standards with specific time frames. Strong problem-solving, analytical and decision-making skills. Organization, planning skills and work with minimal supervision. Well-developed time management and prioritization required. Excellent customer servicing and positive interpersonal/relationship building. Supports diversity and inclusion. Display a positive attitude, take ownership and be accountable.
CERTIFICATIONS/LICENSURES REQUIRED:
Current, valid Michigan license to practice as a Registered Nurse without any conditions, limitations or restrictions.
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.