[Hiring] Concurrent Denial Nurse BU - Utilization Management @Cleveland Clinic

Role Description

Join the Cleveland Clinic team where you will work alongside passionate caregivers and provide patient-first healthcare. As a Concurrent Denial Nurse, you will support the Utilization Management Department by reviewing concurrent and retrospective clinical inpatient denials to ensure medical necessity criteria is met.

• Serve as the expert in Utilization Management functions and be a resource to the department in general and the hospital.
• Review and analyze concurrent and retrospective clinical denials and follow the specific payer processes.
• Serve as an expert in payer specific process and communicate between payer and CCIRH to identify/resolve denial process issues.
• Work in collaboration with the local physician advisor team and support the peer-to-peer process.
• Perform the routine activities of a UM Specialist when needed while taking a leadership role.
• Utilize knowledge of medical terminology, anatomy and physiology, diagnosis, surgical procedures and basic disease processes.
• Utilize knowledge and experience with Care Guidelines and/or other UM criteria sets.
• Utilize advanced interpersonal and communication written and verbal skills necessary to gather and exchange data (both internally and externally) with members of the health care team.
• Recommend resource utilization when needed.
• Utilize analytical skills to gather data, identify problems and facilitate resolution.
• Prioritize and organize work to meet changing priorities.
• Utilize knowledge of multiple hospital information systems and department’s software.
• Assist with education and monitoring of UM specialist's reviews.
• Participate in payer specific p2p calls or local meetings as needed.

Qualifications

• Completion of an accredited Registered Nursing Program (RN)
• Current valid license in the State of Florida as a Registered Nurse (RN)
• Basic Life Support (BLS) certification through the American Heart Association (AHA) or American Red Cross
• Three years of full-time Utilization Management experience
• Demonstrated above average competence in Utilization Management Processes

Requirements

• Case Management certification (CCM or ACM) - Preferred
• Bachelor’s Degree in Nursing or related field - Preferred

Physical Requirements

• Requires extensive reading, telephone, computer use
• Must be able to work well under pressure and maintain professional demeanor under adverse conditions

Personal Protective Equipment

• Follows Standard Precautions using personal protective equipment as required