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Concurrent Denial Nurse – Utilization Management

Cleveland, OH, US


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req#: 279965
Location: Cleveland, OH

Facilities: Remote Location,

Professional Area: Nursing Non Patient Care

Department: 6002 Nursing Administrative Supervisors-Indian River Hospital

Job Code: 0019IR

Schedule: Full Time

Shift: Days

Concurrent Denial Nurse BU — Utilization Management 

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.    

In this role you will support the Utilization Management Department by reviewing concurrent and retrospective clinical inpatient denials to ensure medical necessity criteria is met. We are looking for a Nurse who is a subject matter expert in utilization management and has experience with MCG criteria and comfortable educating Caregivers and Physicians. 

A caregiver in this position works 8:00am—4:30pm.  

A caregiver who excels in this role will:  

  • Serve as the expert in Utilization Management functions and is a resource to the department in general and the hospital 

  • Review and analyze concurrent and retrospective clinical denials and follows the specific payer processes 

  • Serve as an expert in payer specific process and communicates between payer and CCIRH to identify/resolve denial process issues 

  • Work in collaboration with the local physician advisor team, and supports the peer-to-peer process 

  • Perform the routine activities of a UM Specialist when needed while taking a leadership role 

  • Utilize knowledge of medical terminology, anatomy and physiology, diagnosis, surgical procedures, and basic disease processes 

  • Utilize knowledge and experience with Care Guidelines and /or other UM criteria sets 

  • Utilize advanced interpersonal and communication written and verbal skills necessary to gather and exchange data (both internally and externally) with members of the health care team 

  • Recommend resource utilization when needed 

  • Utilize analytical skills to gather data, identify problems, facilitate resolution 

  • Prioritize and organize work to meet changing priorities 

  • Utilize knowledge of multiple hospital information systems and department’s software 

  • Assist with education and monitoring of UM specialist's reviews 

  • Participate in payer specific p2p calls or local meetings as needed 

 

Minimum qualifications for the ideal future caregiver include:  

  • Completion of an accredited Registered Nursing Program (RN). 

  • Bachelor’s degree in Nursing or related field. 

  • Current valid license in the State of Florida as a Registered Nurse (RN). 

  • Proof of Basic Life Support (BLS) certification. 

  • Three years of full-time Utilization Management experience. 

  • Demonstrated above average competence in Utilization Management Processes. 

 
Preferred qualifications for the ideal future caregiver include:  

  • Case Management certification (CCM or ACM). 

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 reading, telephone , computer use

  • Must be able to work well under pressure and maintain professional demeanor under adverse conditions

Personal Protective Equipment:

  • Follows Standard Precautions using personal protective equipment as required

Salaries [which may be] shown on independent job search websites reflect various market averages and do not represent information obtained directly from The Cleveland Clinic. Because we value each individual candidate, we invite and encourage each candidate to discuss salary/hourly specifics during the application and hiring process.

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 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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