RN Utilization Review Specialist - Utilization Management

Responsibilities & Requirements

• Registered professional nurse with education, knowledge and experience.
• Role focuses on review of inpatient and observation admissions to ensure correct assignment of Admit status. Communicates concurrently and resolves medical necessity discrepancies with physicians and other hospital leadership as needed.
• Responsible for completing clinical review on all assigned patients and communicates these reviews to payers.
• Identifies potential or actual denials for admission or ongoing stay both during the patient’s hospital stay and post discharge.
• Review and decide the validity of medical necessity payer denials. Submits payer denial appeals.
• Participates in design of work flows and procedure to reduce incidence of denials.
• Current unrestricted Ohio RN licensure, BSN required.
  
  

Preferred Qualifications

• 5 years clinical experience with 2 years case management preferred
• Case Management certification preferred
• Works independently
• Familiar with MCG Care guidelines
• Ability to adapt quickly to changing priorities and regulations
• Experience with computers required. Experience with Microsoft applications and EPIC software preferred
  
  

Overview

Kettering Health is a not-for-profit system of 14 medical centers and more than 120 outpatient facilities serving southwest Ohio. Our mission is to live God’s love by promoting and restoring health. Our commitment to our patients is to help individuals be their best. With that context, safety is our top priority. We provide an integrated system of healthcare experts committed to providing exceptional care.