Job Information
Corewell Health Utilization Mgmt Coordinator in Southfield, Michigan
Job Summary
This role includes accountability for utilization review (UR) and may include admission, concurrent, and retrospective reviews. Coordinates activities involved in the certification, recertification, and concurrent appeals process, conducting referrals for 2nd level review, as needed. Ensures timely communication with payers based on adequate and complete documentation received by the physician/provider and utilization reviews. Initiates concurrent appeals to address patient class/status downgrades or clinical denials related to medical necessity.
Essential Functions
Participates within the department to meet expected objectives and outcomes.
Meets or exceeds expectations related to behavior and performance. Meets individual and departmental objectives established for Quality, Satisfaction, Growth and Financial Success.
Conducts timely and accurate utilization reviews, as assigned, using organization-approved UR criteria.
Works closely with physician advisors and medical staff to ensure appropriate level of care, including obtaining physician orders for patient class changes when needed.
Refers cases, as defined, for 2nd level medical necessity review.
Maintains daily contact with payers to obtain authorization and reauthorization information and addresses concurrent denials and/or audit requests.
Provides UR and clinical documentation is adequate and complies with payer requirements.
Schedules next review/follow-up reviews as required in accordance with organizational policy and procedure and payer requests.
Routinely collaborates with the System Clinical Appeals and Revenue Cycle departments to expedite billing and appeals processes.
Maintains and monitors assigned work queues within the Electronic Medical Record.
Qualifications
Required Associate's Degree Associates or technical degree.
Preferred Bachelor's Degree in nursing or related field.
2 years of relevant experience 2 years of experience in clinical/hospital setting. Required
Hospital utilization review/utilization management experience. Preferred
Clinical appeals experience. Preferred
LIC-Registered Nurse (RN) - STATE_MI State of Michigan Upon Hire required
Physical Demands
Pallet to Waist (6" from floor) > 5 lbs: Seldom up to 50 lbs
Waist to Waist > 5 lbs: Seldom up to 50 lbs
Waist to Chest (below shoulder) > 5 lbs: Seldom up to 10 lbs
Waist to Overhead > 5 lbs: Seldom up to 5 lbs
Bilateral Carry > 5 lbs: Seldom up to 25 lbs
Unilateral Carry > 5 lbs: Seldom up to 10 lbs
Pushing Force > 5 lbs: Occasionally up to 25 lbs
Pulling Force > 5 lbs: Occasionally up to 20 lbs
Sitting: Occasionally
Standing: Frequently
Walking: Frequently
Forward Bend - Standing: Occasionally
Forward Bend - Sitting: Occasionally
Trunk Rotation - Standing: Occasionally
Trunk Rotation - Sitting: Occasionally
Squat: Seldom
Stair Climbing: Seldom
Crawling / Kneeling: Seldom
Reach - Above Shoulder: Occasionally
Reach - at Shoulder or Below: Occasionally
Handling: Occasionally
Forceful Grip > 5 lbs: Occasionally
Forceful Pinch > 2 lbs: Occasionally
Finger/Hand Dexterity: Frequently
Visual Acuity ¹ [None = No; Seldom = Yes]: Seldom
Color Vision (Ishihara) Test [None = No; Seldom = Yes]: Seldom
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, 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 - Beaumont Service Center - 26901 Beaumont Blvd
Department Name
Utilization Management - CH East
Employment Type
Full time
Shift
Day (United States of America)
Weekly Scheduled Hours
40
Hours of Work
8A-430P
Days Worked
Monday to Friday
Weekend Frequency
N/A
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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.