Employment Type:

Part time

Shift:

Day Shift

Description:

I Accountability Objectives:

Applies specific criteria and payer guidelines to ensure that all health care services provided are cost effective and delivered in the most appropriate setting and optimized for quality and timeliness of the care. In collaboration with members of the health care team, conducts observation, admission, concurrent, discharge and retrospective reviews to evaluate the appropriate level of care, continued stay and status of discharge planning.

II Position Qualifications:

Minimum Education, Licensure / Certification and Experience Required.

A. Education

Associates in Nursing , Bachelor's Degree in Nursing preferred .

B. Licensure / Certification

Current RN licensure within the State of Michigan.

Certified Professional in Utilization Review/Management preferred.

C Special Skill / Aptitudes

Understanding of computers and software in order to collect and report information for required data sources.

Ability to work autonomously with little direction and be accountable for outcomes.

Excellent verbal and written communication skills.

Excellent customer service orientation skills necessary in order to deal effectively with various levels of hospital personnel, outside customers and community groups.

D. Experience

Three years recent acute care utilization management experience.

Knowledge of regulations relative to utilization review. Knowledge of Federal, State and Local regulations sources.

III Duties / Responsibilities:

1 Performs all aspects of utilization review (observation, admission, concurrent and retrospective) to ensure the medical necessity of acute care hospitalization has the existence of supportive documentation in the electronic medical record, as well as appropriate utilization of resources. Provides all external review organizations the information necessary to complete reviews and effect maximum financial reimbursement.

2 Refers all cases lacking IS/SI criteria for acute care hospitalization to the Physician Advisor or designee according to the established department guidelines.

3 Collaborates with Case Management on identifying those patients not meeting the acute care criteria and works with case manager to gather additional clinical information for reimbursement.

4 Provides consultation and information to physicians, case management and other members of the health care team regarding third party payor criteria and documentation requirements.

5 Reviews uses of diagnostic and treatment services ordered by physicians for conditions unrelated to patience's reason for hospitalization; identifies opportunities to defer those services when appropriate to reduce costs.

6 Acts as liaison between 3rd party payer case management and hospital case management to obtain the necessary clinical information to secure authorization of entire hospital stay.

7 Participates in hospital and departmental process and quality improvement initiatives.

8 Maintains competency in field as defined by continually meeting established job qualifications, competencies and certification requirements.

9 Obtains inpatient/observation orders and enters in the electronic medical record.

10 Participates in the appeal process when deemed necessary by the Denials Management Specialist on cases where payment has been denied.

Our Commitment to Diversity and Inclusion

Trinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and inclusion in all that we do. Our colleagues have different lived experiences, customs, abilities, and talents. Together, we become our best selves. A diverse and inclusive workforce provides the most accessible and equitable care for those we serve. Trinity Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by law.

Our Commitment to Diversity and Inclusion

Trinity Health is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians across 25 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.

Our dedication to diversity includes a unified workforce (through training and education, recruitment, retention, and development), commitment and accountability, communication, community partnerships, and supplier diversity.

EOE including disability/veteran