Location: METROHEALTH MEDICAL CENTER

Biweekly Hours: 80.00

Shift: 7a-330p

Summary:

Organizes and manages the activties of the Utilization Review department specifically focusing on clinical utilization reviews, timeliness, accuracy, and denial prevention. Oversees the application of clinical criteria to ensure medical necessity, correct patient status and level of care. Works with payors and providers to establish and maintain processes that ensure accurate and timely utilization review that is consistent with contractual agreements. Collaborates with MH Admissions and Financial Clearance department to develop and revise processes to meet regulatory and payor requirements. Serves as a clinical resource to the physician group and Utilization Review team and support staff and management. Upholds the standards of the system-wide customer service program.

Qualifications:

Registered Nurse with valid Ohio licensure.Bachelor's Degree in Nursing. Four years equivalent work experience in utilization review/case management may be considered in lieu of degree.Five years experience in case management to include experience with medical necessity criteria, such as Inter Qual and MCG.Strong analytical and trouble shooting skills.Strong communication skills.Strong computer skills including excel and word.Ability to interact effectively with a wide range of cultural, ethnic, racial, and socioeconomic backgrounds.Preferred:EPIC experience.Master's degree in related field.Supervisory experience.Physical Requirements:May sit, stand, stoop, bend, and ambulate intermittently during the day. May need to sit or stand for extended periods.See in the normal visual range with or without correction.Hear in the normal audio range with or without correction.Finger dexterity to operate office equipment required. May need to lift up to twenty-five (25) pounds on occasion. Ability to use computer.Ability to communicate in face-to-face, phone, email, and other communications.Ability to read job-related documents.