What are the responsibilities and job description for the RN Utilization Review Specialist position at Spectrum Health?
Scope of Work Provides health information, interacts and acts as a resource for nursing units for complex clinical situations to ensure appropriate use of acute care services and diagnosis-related group (DRG) management. Assesses appropriateness of inpatient admissions and continued stay. Educates medical staff / other health care professionals regarding utilization management and quality requirements. Makes recommendations and provides financial and utilization management (UM) information to other members of the care facilitation teams for work prioritization. Works closely with inpatient care facilitators and Medical Social Workers to move patients through the continuum appropriately.
- Assesses and interprets clinical information and assists in case management of complex patient population, through use of independent judgment, mature problem solving skills, and guidelines for appropriateness of acute care setting upon admission and continued stay.
- Adjusts patient registration status code, as needed, to maximize reimbursement and be consistent with regulatory standards.
- Communicates with physicians, medical social workers, and other hospital personnel concerning change in level of care on the medically complex patient population. Makes recommendations and discusses alternatives. Provides financial / DRG, UM, health information to other facilitation team members for work prioritization. Communicates and collaborates with physicians and members of the team to ensure continuity and coordination of services.
- Documents any instances where services were delayed, inappropriate, refused, complicated, etc. for resource management functions.
- Identifies quality indicators to facilitate process improvement and physician education.
Qualifications
How Corewell Health cares for you
Comprehensive benefits package to meet your financial, health, and work / life balance goals. Learn more .
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, pet 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 - 4700 60th St - Grand Rapids
Department Name
Utilization Management - GR
Employment Type
Full time
Shift
Day (United States of America)
Weekly Scheduled Hours
Hours of Work
Day shift
Days Worked
Monday thru Friday
Weekend Frequency
N / A
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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.
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