Utilization Management Nurse

Ascension Health Sterling Heights, MI
Job ID: 258989Utilization Management NurseSterling Heights, MichiganRegular / Day

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Additional Job Information

Title: Utilization Management Nurse

City, State: Sterling Heights, MI

Location: US Health Holdings/ABS

Department: ACO Care Management 001

Additional Job Details: FT, Days

About Us

Ascension is a faith-based healthcare organization dedicated to transformation through innovation across the continuum of care. As the largest non-profit health system in the U.S. and the world's largest Catholic health system, Ascension is committed to delivering compassionate, personalized care to all, with special attention to persons living in poverty and those most vulnerable. In FY2017, Ascension provided more than $1.8 billion in care of persons living in poverty and other community benefit programs. Ascension includes approximately 165,000 associates and 34,000 aligned providers. Ascension's Healthcare Division operates more than 2,600 sites of care – including 153 hospitals and more than 50 senior living facilities – in 22 states and the District of Columbia, while its Solutions Division provides a variety of services and solutions including physician practice management, venture capital investing, investment management, biomedical engineering, facilities management, clinical care management, information services, risk management, and contracting through Ascension's own group purchasing organization.

Job Description

Job Summary:

The Utilization Management Nurse coordinates with physicians offices and insurance companies in obtaining authorization for all hospital admissions.


* Obtains authorization on for admissions as required by health plans.

* Enters patient insurance authorizations and any pertinent information from insurance company into the patient account history.

* Documents insurance coverage of services to be provided.

* Notifies case management about interactions with insurance companies regarding services.

* Manages denials or potential denials as described by insurer.

* Monitors and reviews applicable schedule to ensure that authorization and initial length of stay is obtained and on file.

* Performs clinical utilization review to determine medical necessity and cost-effectiveness of requested health care services.

* Researches cases and applies medical criteria and clinical judgment to evaluate and render determinations for authorization requests for medical services.Refers cases that require additional expertise and all denials to the Medical Director for review.

* Ensures provider and facility requests are processed appropriately in the clinical IT platform by clinical support associates, including data entry accuracy and timeliness of requests.Reviews clinical information for concurrent reviews, extending the Length of Stay for inpatients as appropriate.

* Establishes effective rapport with other department associates, professional and support service associates, customers, clients, members, families and physicians.

* Uses effective relationship management, coordination of services, resource management, education, patient advocacy, plan policy and related interventions to:a. Promote improved quality of careb. Promote cost effective medical outcomesc.

* Authorize plan benefits according to policy and medical criteriad.

* Prevent hospitalizations when possible and appropriatee. Promote decreased length of hospital stay as appropriatef.

* Provide for continuity of careg. Assure appropriate level of care is provided

* Provides consultation and referral to case management program as appropriate and according to policy.

* Provides advice and counsel to precertification nurses and clinical support associates.Identifies appropriate alternative and non-traditional resources and demonstrates creativity in managing cases to fully utilize all available resources according to the plan document.

* Tracks and monitors metrics as defined by plan administration and provides reports as needed.

* Documents and maintains accurate records of all communications and interventions.

* Assists in population health management; collaborates with pharmacy benefit manager and stop loss carrier as needed.

* Collaborates with customer service regarding benefits and eligibility and the claims department to assist with medicalcoverage and benefit questions, according to the plan document.

* Assists in the development of clinical criteria and authorization guidelines through literature reviews and related research; creates draft documents for medical director and committee review and approval.

* Revises and updates documents as necessary.

* Responsible for ensuring accurate prior authorization process of incoming prior authorizations from providers,reviewing documentation for decision and composing correspondence to communicate clinical decisions to parties involved.

* Assists in the review of appeals cases for first level and retro authorizations.

* Collaborates to ensure accurate and timely review of appeals cases and assists in the appeal process as needed.



* Required Credential(s):

* Licensed Registered Nurse


* High School diploma or GED required, Bachelor's degree preferred

Work Experience:

* Minimum 2-4 years of Acute Care experience required

* Previous Utilization Management experience preferredManaged care (HMO,PPO, Medicare Advantage, Medicaid) experience preferred

* Previous experience in health insurance or other health-related field preferred

Equal Employment Opportunity

Ascension Health is an EEO/AA employer: M/F/Disabled/Vet. For further information regarding your EEO rights, click on the following link to the "EEO is the Law" poster:


Please note that Ascension will make an offer of employment only to individuals who have applied for a position using our official application. Be on alert for possible fraudulent offers of employment. Ascension will not solicit money or banking information from applicants.

E-Verify Statement

Ascension Health participates in the Electronic Employment Verification Program. Please click the E-Verify link below for more information.

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