Insurance Utilization Review Jobs in Michigan (NOW HIRING)

Part time- 20 hours a week

Scope of Work:

Under general direction, integrates cost, quality and utilization to facilitate the admission, continued stay and discharge of the patient. Reviews and evaluates appropriateness of admission or continued stay based on medical necessity. The overall goal of the position is to enhance the quality of patient care and engagement, to promote continuity of care and cost effectiveness through the integration and functions of utilization management, and/or care coordination, discharge planning, and appropriate care transitions. Has accountability for the care coordination and discharge planning of all hospitalized patients.

• Identifies patients that need care management services (i.e. utilization review; care coordination; and/or discharge/transition planning).

• Responsible for managing a case load of patients that includes facilitating utilization management, and/or care coordination during the patient’s stay, planning and expediting plans for safe and effective discharge and transition to the appropriate level of care and setting needed after hospitalization. Coordinating care by considering all patient’s needs.

• Uses critical thinking and effective judgment to determine alternative courses of care. Judiciously uses tools designed to expedite care while being cost effective. Actively participates in readmission initiatives and strategies to maximize patient flow and appropriate resource utilization. Works collaboratively on processes to provide effective transition for patients utilizing hospital outpatient, observation or inpatient services.

• May review cases for medical necessity, uses InterQual and/or other UR/UM Committee-approved medical necessity screening criteria, when appropriate. Works collaboratively with departmental, revenue cycle, and clinical appeals staff, physicians, and payers to obtain authorization for care and appropriate reimbursement. Determines and assures appropriate status and level of care. Uses defined resources to guide decisions, including Medical Director Care Management, Physician Advisors, and management staff.

• Routinely communicates with payers, patients/family caregivers, physicians, the interdisciplinary team, post-acute and community-based care providers to facilitate coordination of care and to enhance a seamless transition from hospital setting to the appropriate alternative level of care.

• Seeks out information and resources to apply creative problem solving for complex discharge/transition planning, quality of care, and utilization management issues. Provides notification and communication to patients/families regarding coverage for hospital and post-acute services, in accordance with CMS regulations.

• Documents utilization reviews, utilization management actions, care management assessment(s), care plan, discharge plan, and interventions, according to policies, procedures, and regulatory, contractual, and legal requirements. Acts proactively to see that hospital resources are utilized appropriately.

• Works collaboratively with other departments to define areas of hospital inefficiency and participates in improvement projects.

Qualifications

• Required Bachelor's Degree Graduate of an accredited school of nursing.

• Required Will consider non-BSN RN if actively pursuing a Bachelors degree in nursing with completion within 2 years of hire.

• 2 years of relevant experience Minimum two years’ experience in the acute care setting. Required

• 3 years of relevant experience Three to five years’ experience in care management, utilization review, home care and/or discharge planning. Preferred

• Registered Nurse (RN) - State of Michigan Upon Hire required

• Basic Life Support (BLS) - AHA American Heart Association preferred Or

• Basic Life Support (BLS) - ARC American Red Cross preferred

• Case Manager, Certified (CCM) - CCMC Commission for Case Manager Certification Upon Hire preferred

How Corewell Health cares for you

• Comprehensive benefits package to meet your financial, health, and work/life balance goals. Learn more here (https://careers.corewellhealth.org/us/en/benefits-new) .

• 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 - Grosse Pointe Hospital - 468 Cadieux Rd - Grosse Pointe

Department Name

Care Management - Grosse Pointe Hosp

Employment Type

Part time

Shift

Day (United States of America)

Weekly Scheduled Hours

20

Hours of Work

8:00 a.m. to 4:30 p.m.

Days Worked

Monday to Friday

Weekend Frequency

Variable weekends

CURRENT COREWELL HEALTH TEAM MEMBERS – Please apply through Find Jobs from your Workday team member account. This career site is for Non-Corewell Health team members only.

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. We invite those that share in our commitment to join our team.

You may request assistance in completing the application process by calling 616.486.7447.