[Hiring] Utilization Review Nurse - Employee Health Plan @Cleveland Clinic

Role Description

Join the Cleveland Clinic team, where you will work alongside passionate caregivers and provide patient-first healthcare. Cleveland Clinic is recognized as one of the top hospitals in the nation. At Cleveland Clinic, you will receive endless support and appreciation and build a rewarding career with one of the most respected healthcare organizations in the world.

As a Utilization Review Nurse, you will:

• Provide clinical information to insurance companies to obtain authorization for future and elective surgeries.
• Coordinate peer-to-peer reviews between insurance Medical Directors and Cleveland Clinic physicians.
• Manage all pre-determination cases, primarily supporting utilization review with a strong focus on outpatient prior authorization requests.
• Work remotely from 8:00 a.m. – 4:30 p.m.
• Be required to reside in northeast Ohio.

A caregiver who excels in this role will:

• Provide insurance companies with detailed clinical information when required to complete the authorization and pre-certification process.
• Communicate and attempt to resolve level of service discrepancies between CCF and insurance companies.
• Coordinate level of service justification directly with physicians and communicate directly with third-party payers to obtain approval.
• Complete responses on behalf of physicians for denials.
• Review medical records and communicate with physicians to obtain authorization.
• Coordinate peer-to-peer reviews with CCF physicians and the insurance company Medical Director.
• Coordinate pre-determinations for specific procedures and maintain confidentiality of all patients' related information.
• Adhere to all JCAHO and Medicare compliance regulations.

Qualifications

• Graduate of an accredited practical/vocational or professional nursing program.
• Current state licensure as a Licensed Practical Nurse (LPN) or Registered Nurse (RN).
• Two or more years of experience in coding or a patient care acute facility, preferably at a tertiary care medical center.
• Excellent communication skills required to communicate with all levels in a healthcare environment.

Requirements

• Utilization Review experience (preferred).
• Epic experience (preferred).

Benefits

• Follows standard precautions using personal protective equipment as required.
• Participation in an influenza prevention program, including obtaining an annual influenza vaccination or an approved exemption.