[Hiring] Concurrent Denial Nurse BU - Utilization Management @Cleveland Clinic

This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description Join the Cleveland Clinic team where you will work alongside passionate caregivers and provide patient-first healthcare. As a Concurrent Denial Nurse, you will support the Utilization Management Department by reviewing concurrent and retrospective clinical inpatient denials to ensure medical necessity criteria is met. • Serve as the expert in Utilization Management functions and be a resource to the department in general and the hospital. • Review and analyze concurrent and retrospective clinical denials and follow the specific payer processes. • Serve as an expert in payer specific process and communicate between payer and CCIRH to identify/resolve denial process issues. • Work in collaboration with the local physician advisor team and support the peer-to-peer process. • Perform the routine activities of a UM Specialist when needed while taking a leadership role. • Utilize knowledge of medical terminology, anatomy and physiology, diagnosis, surgical procedures and basic disease processes. • Utilize knowledge and experience with Care Guidelines and/or other UM criteria sets. • Utilize advanced interpersonal and communication written and verbal skills necessary to gather and exchange data (both internally and externally) with members of the health care team. • Recommend resource utilization when needed. • Utilize analytical skills to gather data, identify problems and facilitate resolution. • Prioritize and organize work to meet changing priorities. • Utilize knowledge of multiple hospital information systems and department’s software. • Assist with education and monitoring of UM specialist's reviews. • Participate in payer specific p2p calls or local meetings as needed. Qualifications • Completion of an accredited Registered Nursing Program (RN) • Current valid license in the State of Florida as a Registered Nurse (RN) • Basic Life Support (BLS) certification through the American Heart Association (AHA) or American Red Cross • Three years of full-time Utilization Management experience • Demonstrated above average competence in Utilization Management Processes Requirements • Case Management certification (CCM or ACM) - Preferred • Bachelor’s Degree in Nursing or related field - Preferred Physical Requirements • Requires extensive reading, telephone, computer use • Must be able to work well under pressure and maintain professional demeanor under adverse conditions Personal Protective Equipment • Follows Standard Precautions using personal protective equipment as required Apply tot his job