Utilization Management Specialist NE

Join 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. Your work impacts the denial rate, which in return would impact patients out of pocket expenses. Here, you will have the opportunity to work with a dynamic team of like-minded individuals and have the chance to grow your skills into a supervisor role.  

A PRN caregiver in this position works varying days from 7:30AM – 4:30PM.  

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 quarterly. 

• Complete 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 (Diploma, ADN or BSN program) 

• Current state licensure as a Registered Nurse (RN)  

• Basic Life Support (BLS) certification through the American Heart Association (AHA) or American Red Cross 

• Three years of equivalent full-time clinical experience as a Registered Nurse 

• 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 

• Advanced interpersonal and communication written and verbal skills 

• Ability to assess medical records and determine stay length and proper procedures in accordance with policies and procedures 

• Demonstrated competence in all areas identified in the Competencies, Dimensions, Problem Solving and Information Management sections 

• Cognizant of reimbursement denials and effect on cost of care 

• Knowledge of and ability to use multiple Hospital information systems and Department's software 

Preferred qualifications for the ideal future caregiver include: 

• Bachelor of Science in Nursing (BSN)  

• Case Management Certification (CCM) within first year of eligibility 

• Prior Utilization Management experience