Remote Utilization Review Nurse 

The MetroHealth System, Cuyahoga County’s public health system, and its staff of nearly 8,000 provides care at MetroHealth’s four hospitals, four emergency departments and more than 20 health centers and 40 additional sites throughout Cuyahoga County. The health system is home to Cuyahoga County’s most experienced Level I Adult Trauma Center, verified since 1992, and Ohio’s only adult and pediatric trauma and burn center.  As an academic medical center, MetroHealth is committed to teaching and research. Each active staff physician holds a faculty appointment at Case Western Reserve University School of Medicine. Our main campus hospital houses a Cleveland Metropolitan School District high school of science and health. The MetroHealth System is committed to creating a healthier community.

Summary: 

Responsible for supporting the physician and interdisciplinary team in the provision of patient care by ensuring the appropriate level of care at the point of entry. The utilization review nurse will work on defined patient populations and is responsible for an initial clinical review at the point of patient entry to the inpatient care setting, this includes observation status. Will collaborate with other interdisciplinary team members to develop and participate in a systematic approach to denial management, and in so doing reduce organizational exposure to revenue loss. Actively participates in the denial management process; improve reimbursement by optimizing revenue recovery due to inappropriate level of care, failure to meet medical necessity, and/or severity of illness. Upholds the mission, vision, values, and customer service standards of The MetroHealth System.

Responsibilities:

1.Contributes to patient safety by supporting the System-wide programs and policies addressing a safe environment for patients and the reporting of safety concerns to the appropriate individuals

2.Designs and implements clinical necessity criteria for services at the point of entry.

3.On assigned patients, performs an initial clinical review which includes level of care, medical necessity, and targeted length of stay.

4.Utilizes and applies Milliman or industry standard guidelines while assessing level of care, medical necessity, and targeted length of stay.

5.Collaborates with the physician and other team members to assess clinical presentation and apply clinical necessity criteria for the level of care or services ordered. Identifies discrepancies and communicate this information to the physician.

6.Responsible for tracking, monitoring, and the progression of patients in observation status.

7.Establishes and participates in data and outcome management.

8.Collaborates with the patient flow coordinator to ensure the patient is admitted to the most appropriate bed available using criteria for admission and determining if the patient is a candidate for observation or inpatient status.

9.Collaborates with denial management team to identify those denials resulting in revenue loss due to admit type, (should have been assigned observation status) medical necessity, severity of illness, length of stay.

10.Assist with establishing denial management benchmarks as it applies to access, they will reflect industry standards.

11.Will monitor the use of observation beds for length of stay and appropriateness.

12.Performs other job-related duties as assigned.

Qualifications:

Required:
Bachelor’s degree in Nursing (applies to placements after 1/1/2017).
Current Registered Nurse License State of Ohio.
Minimum of five years clinical experience.
Able to work independently and as a member of an interdisciplinary team.
Knowledge and experience with medical necessity criteria for inpatient admission and observation placement.
Knowledge and experience of denials based on the absence of documented medical necessity or failure to meet severity of illness and intensity of service criteria.
Knowledge of internal criteria set and Milliman Health Management Guidelines.
Excellent interpersonal communication and negotiation skills.
Strong analytical, data management, and PC skills.
Current working knowledge of, utilization management, case-management, performance improvement, and managed care reimbursement.
Strong organizational and time management skills.

Preferred:
Two years of experience with case management, utilization review.

Physical Demands:
May need to move around intermittently during the day, including sitting, standing, stooping, bending, and ambulating.
May need to remain still for extended periods, including sitting and standing.
Ability to communicate in face-to-face, phone, email, and other communications.
Ability to read job related documents.
Ability to use computer.