RN Utilization Review at Ascension Health

About the position

The Trauma Administration department at Ascension Providence Southfield is seeking a dedicated Registered Nurse to join our team. This full-time position requires a commitment of 40 hours per week, primarily during the day. The role involves providing comprehensive health care services related to admissions, case management, discharge planning, and utilization review. The successful candidate will be responsible for reviewing admissions and service requests within the assigned unit, ensuring compliance with medical necessity and reimbursement policy criteria. This position also entails providing case management and consultation for complex cases, assisting departmental staff with coding, medical records, precertification, and addressing claim denials and appeals. In addition to these responsibilities, the Registered Nurse will assess and coordinate discharge planning needs in collaboration with healthcare team members. The role may also involve preparing statistical analyses and utilization review reports as necessary. A critical aspect of this position is overseeing and coordinating compliance with federally mandated and third-party payer utilization management rules and regulations. Joining Ascension Michigan means becoming part of a leading non-profit, faith-based national health system that operates 16 hospitals and over 300 related healthcare facilities. Our mission is to provide spiritually centered, holistic care that sustains and improves the health of the communities we serve throughout Michigan. As a member of our care teams, you will be empowered to give back, volunteer, and make a positive impact in your community, enhancing not only your life but also the lives of those around you.

Responsibilities
• Provide health care services regarding admissions, case management, discharge planning and utilization review.
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• Review admissions and service requests within assigned unit for prospective, concurrent and retrospective medical necessity and/or compliance with reimbursement policy criteria.
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• Provide case management and/or consultation for complex cases.
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• Assist departmental staff with issues related to coding, medical records/documentation, precertification, reimbursement and claim denials/appeals.
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• Assess and coordinate discharge planning needs with healthcare team members.
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• Prepare statistical analysis and utilization review reports as necessary.
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• Oversee and coordinate compliance to federally mandated and third party payer utilization management rules and regulations.

Requirements
• Registered Nurse credentialed from the Michigan Board of Nursing obtained prior to hire date or job transfer date required.
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• Diploma from an accredited school/college of nursing OR required professional licensure at time of hire.
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• 5 years minimum of clinical experience as a Registered Nurse (BSN preferred) or equivalent; trauma experience preferred.
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• Previous experience with data abstraction from medical records, and or analyzing and interpreting processes of care, and clinical outcomes is preferred.
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• Excellent written and verbal communication skills.
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• Working knowledge of computer software (Microsoft and Google) and trauma registry applications.

Nice-to-haves
• BSN preferred for clinical experience as a Registered Nurse.
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• Experience in trauma care is preferred.

Benefits
• Paid time off (PTO)
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• Various health insurance options & wellness plans
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• Retirement benefits including employer match plans
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• Long-term & short-term disability
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• Employee assistance programs (EAP)
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• Parental leave & adoption assistance
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• Tuition reimbursement
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• Ways to give back to your community

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