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Utilization Management RN Reviewer
Cleveland Clinic. Perform admission review, concurrent review, retrospective chart review, and clinical systems review .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in Utilization Management, including admission and concurrent reviews, applying medical necessity guidelines, and conducting thorough clinical assessments. Proficient in analyzing clinical performance data and collaborating with clinical teams to ensure optimal patient care and compliance with standards.
Highest-signal resume keywords
Registered Nurse (RN) LicensureUtilization Management ExperienceMedical Necessity GuidelinesAnalytical SkillsBasic Life Support (BLS) Certification
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
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Hard Skills
Clinical Chart ReviewData Collection and ReportingMedical Records Coding StandardsKnowledge of Medical TerminologyAssessment of Treatment PlansUtilization Management DocumentationKnowledge of Billing PracticesCare GuidelinesLength of Stay AssessmentClinical Judgment
Soft Skills
Analytical AbilityInterpersonal CommunicationProblem-Solving SkillsTeam CollaborationAttention to Detail
Tools & Technologies
Microsoft OfficeHospital Information SystemsDepartment SoftwareCopierFax Machine
Certifications & Qualifications
Basic Life Support (BLS)Case Management Certification (CCM)
Industry Keywords
Utilization ManagementClinical PerformancePatient Stay StatusAccreditation StandardsEmergency Room Experience
About the role
Key responsibilities & impact- Perform admission review, concurrent review, retrospective chart review, and clinical systems review
- Measure clinical performance and utilization management issues affecting reimbursement
- Review medical records and provide clinical information to payers
- Collect and report utilization management data
- Participate in concurrent denials appeals processes
- Interact with clinical teams and Physician Advisers
- Participate in special projects and focused reviews
- Recommend resource utilization
- Apply clinical judgment and predetermined criteria to identify problems and facilitate resolution
- Determine patient stay status, appropriateness of treatment plans, continued stay, and discharge-plan safety
- Recommend corrective actions and report results
- Complete utilization management for assigned patients, conducting at least 25–30 reviews per day
- Achieve a minimum quarterly IRR score of 85%
- Apply medical necessity guidelines to monitor admissions and continued stays
- Document UM notes demonstrating that the UR process was followed
- Attend scheduled staff meetings
- Perform other duties as assigned
- Work remotely from 7:30 a.m.–4:00 p.m. with weekend requirements
Requirements
What you’ll need- Graduate of an accredited school of nursing
- Current state licensure as a Registered Nurse (RN)
- Basic Life Support (BLS) certification through the American Heart Association (AHA) or American Red Cross
- Three years of equivalent full-time clinical experience as a Registered Nurse
- Knowledge of medical terminology, anatomy and physiology, diagnosis, surgical procedures, and basic disease processes
- Analytical ability to gather data and identify problems
- Basic knowledge of medical records coding standards
- Awareness of licensing and accreditation standards
- Proficient with Microsoft Office
- Knowledge of billing practices, billing problems, documentation adequacy, research, and formulating recommendations
- Knowledge and experience with Care Guidelines, Medical Necessity Criteria and/or other UM criteria sets
- Ability to assess medical records and determine length of stay and proper procedures
- Knowledge of and ability to use multiple hospital information systems and department software
- Ability to use a copier, fax machine, and personal computer
- Preferred: Bachelor of Science in Nursing (BSN)
- Case Management Certification (CCM) preferred within first year of eligibility
- Preferred: prior Utilization Management experience
- Preferred: case management or ED experience
- Preferred: emergency room experience
- Must comply with annual influenza vaccination or obtain an approved exemption
- Must complete post-offer controlled-substance testing
Benefits
Comp & perks- Remote work from 7:30 a.m.–4:00 p.m.
- Full-time employment
- Support and appreciation from Cleveland Clinic
- Rewarding career with Cleveland Clinic Health System
- Annual influenza vaccination or approved exemption program
- Drug-free workplace with post-offer controlled-substance testing