Utilization Nurse Review
Join the Cleveland Clinic team where you will work alongside passionate caregivers and provide patient-first healthcare. You will work alongside dedicated caregivers, receive endless support and appreciation, and build a rewarding career with one of the most respected healthcare organizations in the world.
Our RCM Payor Denial Management Team is looking to add a Utilization Nurse Review to the team of caregivers. In this role you will coordinate all pre-determination cases. When you join our team, you will be part of a supportive caregiver family that will be united in shared values and purpose to fulfill our promise of being the best place to receive care and the best place to work in healthcare.
A caregiver in this position works days, 8:00am—4:30pm.
A caregiver who excels in this role will:
Provide insurance company with detailed clinical information to 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 physician and communicates directly with third party payer to obtain approval.
Complete responses on behalf of physician for denials.
Review medical records and communicate with physician to obtain authorization.
Coordinate peer to peer reviews with CCF physician and insurance company Medical Director (reviews are completed for CCF physician at Main Campus and the Community Hospitals).
Coordinate pre-determinations for specific procedures and maintain confidentiality of all patients' related information.
Adhere to all JCAHO and Medicare compliance regulations.
Minimum qualifications for the ideal future caregiver include:
Graduate of an accredited practical/vocational or professional nursing program.
Current state licensure as a 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 verbal and written communications skills required to communicate will all levels in a health care environment.
Excellent customer service, organizational skills along with ability to work under tight deadlines.
Our caregivers continue to create the best outcomes for our patients across each of our facilities. Click the link and see how we’re dedicated to providing what matters most to you: https://jobs.clevelandclinic.org/benefits-2/
Physical Requirements:
Requires extensive sitting and dexterity to perform work on a PC.
Requires walking for extended periods of time.
Good visual acuity through normal or corrected vision.
Sedentary Work - Exerting up to 10 pounds of force occasionally (Occasionally: activity or condition exists up to 1/3 of the time) and/or a negligible amount of force frequently (Frequently: activity or condition exists from 1/3 to 2/3 of the time) to lift, carry, push, pull, or otherwise move objects, including the human body.
Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time.
Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.
Personal Protective Equipment:
Follows standard precautions using personal protective equipment as required.
The policy of Cleveland Clinic Health System and its system hospitals (Cleveland Clinic Health System) is to provide equal opportunity to all of our caregivers and applicants for employment in our tobacco free and drug free environment. All offers of employment are followed by testing for controlled substance and nicotine. All offers of employment are follwed by testing for controlled substances and nicotine. All new caregivers must clear a nicotine test within their 90-day new hire period. Candidates for employment who are impacted by Cleveland Clinic Health System's Smoking Policy will be permitted to reapply for open positions after one year.
Cleveland Clinic Health System administers an influenza prevention program. You will be required to comply with this program, which will include obtaining an influenza vaccination on an annual basis or obtaining an approved exemption.
Decisions concerning employment, transfers and promotions are made upon the basis of the best qualified candidate without regard to color, race, religion, national origin, age, sex, sexual orientation, marital status, ancestry, status as a disabled or Vietnam era veteran or any other characteristic protected by law. Information provided on this application may be shared with any Cleveland Clinic Health System facility.
Please review the Equal Employment Opportunity poster.
Cleveland Clinic Health System is pleased to be an equal employment employer: Women / Minorities / Veterans / Individuals with Disabilities
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