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RN Utilization Mgmt Coordinator LEAD

Company: Beaumont Health
Location: Royal Oak
Posted on: August 5, 2022

Job Description:

GENERAL SUMMARY: -This role includes ensures competency and performance for utilization review (UR) staff. Problem solves for Utilization Management staff and assists with education of new processes and information technology workflows in the electronic health record systems. Performs data compilation and overview analysis of data that supports the site Utilization Management Committee. Reviews electronic health record work queue completion and performs utilization reviews as needed.This role includes accountability for utilization review (UR) and may include admission, concurrent, and retrospective reviews. Coordinates activities involved in the certification, recertification, and concurrent appeals process, conducting referrals for 2nd level review, as needed. Ensures timely communication with payers based on adequate and complete documentation received by the physician/provider and utilization reviews. Initiates concurrent appeals to address patient class/status downgrades or clinical denials related to medical necessity.Assists with Utilization Management department operations to ensure efficiency. Reports to Care Management Director.ESSENTIAL DUTIES:1. Participates within the department to meet expected objectives and outcomes.2. Assists with department Utilization Management educational support regarding staff training, information systems and the electronic medical record (EMR).3. Completes cases in specified work queues in the EMR as identified.4. Meets or exceeds expectations related to behavior and performance. Meets individual and departmental objectives established for Quality, Satisfaction, Growth and Financial Success.5. Conducts timely and accurate utilization reviews, as assigned, using organization-approved UR criteria.6. Refers cases, as defined, for 2nd level medical necessity review.7. Maintains daily contact with payers to obtain authorization and reauthorization information and addresses concurrent denials and/or audit requests.8. Provides UR and clinical documentation is adequate and complies with payer requirements.9. Schedules next review/follow-up reviews as required in accordance with organizational policy and procedure and payer requests.10. Routinely collaborates with the System Clinical Appeals and Revenue Cycle departments to expedite billing and appeals processes.11. Maintains and monitors assigned work queues within the Electronic Medical Record.12. Works collaboratively with other departments to define areas of hospital inefficiency and participates in improvement projects.This document represents the major duties, responsibilities, and authorities of this job, and is not intended to be a complete list of all tasks and functions. It should be understood, therefore, that incumbents may be asked to perform job-related duties beyond those explicitly described.STANDARD REQUIREMENTS:1. Supports the Mission, Value and Vision of Beaumont Health (BH). Demonstrates personal commitment through active involvement in the performance improvement process.2. Exhibits excellent customer service skills and behaviors toward internal and external customers and co-workers. Promotes positive public relations with patients/residents, family members, guests, and others.3. Supports and adheres to all Beaumont Health's customer service, service excellence, and performance standards. Supports and participates with all required compliance standards that may be department specific and/or identified by the organizations including in-service training, acceptable attendance, uniform and dress code.4. Adheres to HIPAA requirements and maintains confidentiality of all data, including patient/resident, employee and operations information.5. Supports and participates in a collaborative team-oriented environment - cooperates and works together with all co-workers, plans and completes job duties, uses appropriate communications in sensitive and emotional situations and follows up as appropriate regarding reported complaints, problems and concerns.6. Supports, cooperates with and demonstrates safe work practices and attitudes, follows safety rules - including universal precautions - reports and prevents/corrects unsafe conditions and behaviors, and participates in organizational and departmental safety programs.7. Completes all required compliance standards that may be department specific and/or identified by the organization.8. Maintains current licensure, registration and/or certification, as applicable, at all times.STANDARD QUALIFICATIONS:To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties.A. Education / Training: --- Associates or technical degree required; Bachelor's degree in nursing or related field preferred.B. Work Experience: --- Hospital utilization review/utilization management experience preferred; Clinical appeals experience desired. --- 3 years of experience in clinical/hospital setting required.C. Certification, Licensure, Registration: --- Requires a current, unrestricted license to practice as a registered nurse in the State of Michigan. Certification in care management preferred.D. Other Qualifications: --- Outstanding organizational and communication skills (written and oral). Computer literate and adept. Impeccable customer service skills.

Keywords: Beaumont Health, Royal Oak , RN Utilization Mgmt Coordinator LEAD, Healthcare , Royal Oak, Michigan

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