Offer summary

Qualifications:

Bachelor's degree in nursing, allied health, business, or related field preferred., Registered Nurse with current unrestricted Michigan Registered Nurse license required., Two to four years of clinical experience in acute patient care, discharge planning, case management, or utilization review., Certification in Case Management may be preferred based on department assignment..

Key responsibilities:

Perform prospective, concurrent, and retrospective review of inpatient and outpatient services to ensure medical necessity and appropriate care levels.

Establish care plans and coordinate care through the health care continuum, including member outreach assessments.

Handle appeal requests initiated by providers, facilities, and members.

Utilize advanced computer skills for documentation and reporting purposes.

Job description

Dept: Commercial Inpatient Pr

Will this position be required to work onsite for any reason at any time? No, resource will be able to perform this role offsite.

Engagement Description – Perform prospective, concurrent and retrospective review of inpatient, outpatient, ambulatory and ancillary services to ensure medical necessity, appropriate length of stay, intensity of service and level of care, including appeal requests initiated by providers, facilities and members. May establish care plans and coordinate care through the health care continuum including member outreach assessments. Bachelor's degree in nursing, allied health, business, or related field preferred. Two (2) to four (4) years of clinical experience which may include acute patient care, discharge planning, case management, and utilization review, etc. Demonstrated clinical knowledge and experience relative to patient care and health care delivery processes. One (1) year health insurance plan experience or managed care environment preferred. Registered Nurse with current unrestricted Michigan Registered Nurse license required. Certification in Case Management may be preferred based upon designated department assignment.

Top 3 Required Skills/Experience –
• 2 years acute care experience with an unrestricted Registered Nurse license
• ICU/ER preferred or for post-acute care positions SNF/Rehab/LTACH) *should not just be 2 years in a specialized field such as NICU/OB/BH/Substance Abuse *
• Advanced computer skills

Required Skills/Experience – The rest of the required skills/experience. Include:

Preferred Skills/Experience – Optional but preferred skills/experience. Include:
• InterQual/MCG or other utilization review experience
• Advanced computer skills
• 40+ WPM typing

Education/Certifications – Include:
• Registered Nurse License

Required profile