Nurse Coordinator (RN)- Care Management

Utilization Review Role

This role includes accountability for utilization review (UR) and may include admission, concurrent, and retrospective reviews. Coordinates activities involved in the certification, recertification, and concurrent appeals process, conducting referrals for 2nd level review, as needed. Ensures timely communication with payers based on adequate and complete documentation received by the physician/provider and utilization reviews. Initiates concurrent appeals to address patient class/status downgrades or clinical denials related to medical necessity.

Participates within the department to meet expected objectives and outcomes. Meets or exceeds expectations related to behavior and performance. Meets individual and departmental objectives established for Quality, Satisfaction, Growth and Financial Success. Conducts timely and accurate utilization reviews, as assigned, using organization-approved UR criteria. Works closely with physician advisors and medical staff to ensure appropriate level of care, including obtaining physician orders for patient class changes when needed. Refers cases, as defined, for 2nd level medical necessity review. Maintains daily contact with payers to obtain authorization and reauthorization information and addresses concurrent denials and/or audit requests. Provides UR and clinical documentation is adequate and complies with payer requirements. Schedules next review/follow-up reviews as required in accordance with organizational policy and procedure and payer requests. Routinely collaborates with the System Clinical Appeals and Revenue Cycle departments to expedite billing and appeals processes. Maintains and monitors assigned work queues within the Electronic Medical Record.

Qualifications

• Required Associate's Degree Associates or technical degree.
• Preferred Bachelor's Degree in nursing or related field.
• 2 years of relevant experience 2 years of experience in clinical/hospital setting. Required
• Hospital utilization review/utilization management experience. Preferred
• Clinical appeals experience. Preferred
• Registered Nurse (RN) - State of Michigan Upon Hire required

How Corewell Health Cares For You

Comprehensive benefits package to meet your financial, health, and work/life balance goals.

On-demand pay program powered by Payactiv

Discounts directory with deals on the things that matter to you, like restaurants, phone plans, spas, and more!

Optional identity theft protection, home and auto insurance

Traditional and Roth retirement options with service contribution and match savings

Eligibility for benefits is determined by employment type and status

Primary Location

SITE - 25800 Northwestern Highway - Southfield

Department Name

Utilization Management - Diversified East WB Mkt

Employment Type

Part time

Shift

Day (United States of America)

Weekly Scheduled Hours

0.04

Hours of Work

8

Days Worked

Monday - Friday

Corewell Health is committed to providing a safe environment for our team members, patients, visitors, and community. We require a drug-free workplace and require team members to comply with the MMR, Varicella, Tdap, and Influenza vaccine requirement if in an on-site or hybrid workplace category. We are committed to supporting prospective team members who require reasonable accommodations to participate in the job application process, to perform the essential functions of a job, or to enjoy equal benefits and privileges of employment due to a disability, pregnancy, or sincerely held religious belief.

Corewell Health grants equal employment opportunity to all qualified persons without regard to race, color, national origin, sex, disability, age, religion, genetic information, marital status, height, weight, gender, pregnancy, sexual orientation, gender identity or expression, veteran status, or any other legally protected category.

An interconnected, collaborative culture where all are encouraged to bring their whole selves to work, is vital to the health of our organization. As a health system, we advocate for equity as we care for our patients, our communities, and each other. From workshops that develop cultural intelligence, to our inclusion resource groups for people to find community and empowerment at work, we are dedicated to ongoing resources that advance our values of diversity, equity, and inclusion in all that we do.

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