Utilization Management Specialist NE Job at Cleveland Clinic in Vero Beach

Under the general supervision of the UM Team Manager, this individual performs UM activities which includes admission review, concurrent review, retrospective chart review and clinical systems review to measure clinical performance and UM issues that affect reimbursement for the patient's hospital stay or visit. Responsibilities include medical record review, providing clinical information to the payer, UM data collection and reporting, concurrent denials appeals process, clinical team interaction, Physician Adviser interaction and special projects which are coordinated and directed by the UM Team Manager. May design and initiate special projects as supervised by the Team Manager.Utilization Management SpecialistJoin our team at Cleveland Clinic Indian River Hospital, and experience world-class healthcare at its best. Cleveland Clinic Indian River has been recognized as one of the top regional hospitals in South Florida. Indian River Hospital is in sunny Florida's Treasure Coast where it is committed to providing optimal family-centric and community-focused care. At Indian River Hospital, you will be part of a collaborative, compassionate, and innovative team of caregivers. You will work with state-of-the-art technology and will build a rewarding career with one of the most respected healthcare organizations in the world.Utilization Management (UM) Specialists perform UM activities, such as admission review, concurrent review, retrospective chart review and clinical systems review to measure clinical performance and UM issues that affect reimbursement for the patient's hospital stay or visit. Some of the responsibilities of a Utilization Management Specialist include medical record review, providing clinical information to payers, UM data collection and reporting, concurrent denials appeals process, clinical team interaction, Physician Adviser interaction and special projects.A caregiver in this position works 7:30AM - 4:00PM.A caregiver who excels in this role will:Recommend resource utilization.Prioritize and organize work to meet changing priorities.Utilize analytical abilities required to gather data.Use clinical judgment to apply predetermined criteria or use independent clinical judgment when no predetermined criteria exist to identify problems, facilitate resolution, recommend corrective action, and report results effectively.Use independent clinical judgment in reviewing records to determine status of patients stay, if proper procedures have been followed, seriousness of incidents and ability to identify need for and participate in focused reviews, special projects and identify opportunities for improvement.Make recommendations regarding appropriateness of the treatment plan for continued stay and safety of the discharge plan.Achieve a minimum of 85% on IRR plete utilization management for assigned patients with at least 25-30 reviews per day.Apply medical necessity guidelines accurately to monitor appropriateness of admission and continued stays.Document appropriately in UM notes to provide evidence that the UR process for the case was followed.Minimum qualifications for the ideal future caregiver include:Graduate from an accredited school of professional nursing.Current state licensure as a Registered Nurse (RN).Basic Life Support (BLS) certification through the American Heart Association (AHA).Three to five years of full-time clinical experience as an RN.Knowledge of medical terminology, anatomy, physiology, diagnosis, surgical procedures, and basic disease processes.Analytical ability to gather data, decide on conformity based on predetermined criteria, identify problems and refer for resolution.Basic knowledge of medical record coding standards.Awareness of licensing and accreditation standards.Proficient with Microsoft Office.Knowledge of billing practices, identification of billing problems, adequacy of documentation, and ability to conduct research of issue at hand, as well as formulate recommendations based on findings.Knowledge and experience with Care Guidelines, Medical Necessity Criteria and/or other UM criteria sets.Ability to assess medical records and make determinations on length of stay and proper procedures in accordance with policies and procedures.Preferred qualifications for the ideal future caregiver include:Bachelor of science in nursing (BSN).Case Management Certification (CCM) preferred.Two years of care management or UM experience.Our caregivers continue to create the best outcomes for our patients across each of our facilities. Click the link and see how we're dedicated to providing what matters most to you: Physical Requirements:Requires walking, sitting, and/or standing for long periods of time.Requires constant attention to detail, reading of medical records, and meeting deadlines.Works in an environment where there is some discomfort due to dust, noise, temperature.Personal Protective Equipment:Follows standard precautions using personal protective equipment.Salaries [which may be] shown on independent job search websites reflect various market averages and do not represent information obtained directly from The Cleveland Clinic. Because we value each individual candidate, we invite and encourage each candidate to discuss salary/hourly specifics during the application and hiring process.