Mercy Medical Center Clinton RN Utilization Review Coordinator, Part Time 0.5 FTE in Grand Rapids, Michigan
GR101_64500 Case Management
Expected Weekly Hours:
Job Description Details:
This position is located in Grand Rapids, MI at our Mercy Health Saint Mary's campus and part of the RN Case Management team!
This position is for part time hours.
Be a part of a collaborative and respected team.
RESPECTED + REWARDED. Be BOTH at Mercy Health!
Please completely fill out the application and upload resume.
This is required to be considered, including internal candidates.
Performs Utilization Reviews for assigned cases, interacting with insurance representatives, case managers, and the physician advisor as needed. Coordinates the utilization review activities within the CQM department and serves as interdepartmental liaison as it relates to changes in the utilization management industry. In addition, assists with denial management of cases denied both concurrently and retrospectively.
Minimum Bachelors of Nursing (BSN)
Minimum Current State of Michigan Registered Nurse License.
(This is only required for those who present themselves as an RN)
Minimum Three years acute care experience as a Registered Nurse or five years demonstrated experience in a similar role
Preferred Two years recent acute care utilization management experience, experience in facility audits/appeals and processes
Other Knowledge, Skills and Abilities
Minimum Demonstrated knowledge of regulation relative to utilization review, current knowledge of third party payer programs and requirements, and criteria utilized, understanding of computers and software (spreadsheet and databases) in order to collect data and provide utilization management reports. Ability to exercise independent judgment. Demonstrated systems analysis and creative corrective strategies. Effective communication skills to collaborate with multiple levels in the organization.
Demonstrates the use (through a competency assessment) of a standard desktop and windows based computer system, including a basic understanding of email, e-learning, intranet and computer navigation. Ability to use other software, as required, to perform the essential functions of the job.
Minimum Sitting most of the day with some walking, shared office (high noise levels),
ability to coordinate and meet deadlines, ability to bend, stoop, and reach above head, and lift and carry. Rare occasion of lifting less than 20 pounds. Use of keyboard and computer.
Performs accurate, complete utilization reviews on patients as assigned. Identifies cases requiring pre-certification and performs certification calls in a courteous, organized, timely, and efficient manner.
Handles utilization denials/appeals in collaboration with manager/director, physician advisor, and other appropriate hospital departments.
Performs necessary concurrent and retrospective changes in patient status (observation versus inpatient) per standard process.
Demonstrates efficiency on Healthquest and Cerner computer systems.
Sets and maintains a professional atmosphere which encourages open communication and demonstrates attention to the needs and concerns of patients, families and health team members.
Identifies inappropriate admissions, non-acute days, under/over utilization of resources, and reports to Manager. Proactively utilizes established criteria plus re-certification data to alert case manager.
Recognizes importance of interdisciplinary collaboration; demonstrates ability to be an effective team player.
When patients don’t meet medical necessity criteria, follows appropriate processes to obtain authorization from third party payers, and/or refers to Saint Mary’s physician advisor for decision as per process.
Performs data collection to meet regulatory requirements.
Communicates with physicians, case managers, etc. as indicated to facilitate correct patient admission status and utilization concerns.
Attends internal and external educational offerings to enhance professional development and maintain current knowledge related to utilization management. Shares information obtained at educational offerings.
Performs other related duties as assigned.
Trinity Health's Commitment to Diversity and Inclusion
Trinity Health employs more than 120,000 colleagues at dozens of hospitals and hundreds of health centers in 21 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.
Trinity Health's dedication to diversity includes a unified workforce (through training and education, recruitment, retention and development), commitment and accountability, communication, community partnerships, and supplier diversity.
Trinity Health offers rewarding careers in a community environment with all the advantages of working at one of the nation's largest health systems. We provide high-quality, people-centered care in 22 states through our network of hospitals, facilities, community-based services, and continuing care locations - including home care, hospice, Program of All Inclusive Care for the Elderly (PACE), and senior living facilities. If you are looking for a rewarding clinical or administrative position, you'll find exceptional career possibilities, opportunities for advancement and a job with meaning at Trinity Health.
Trinity Health employs more than 131,000 colleagues across 22 states. We honor and embrace a diverse representation of people, ideas and backgrounds. Our dedication to diversity is evident in our commitment to training, education, recruitment, retention and development, as well as community partnerships and supplier diversity.
Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences and health practices of the communities we serve and to apply that knowledge to produce positive outcomes. We recognize that each of us has a different way of thinking and perceiving our world, and that our differences not only serve to unite us, but also lead to innovative solutions.