Utilization Review Nurse - Employee Health Plan (EHP)

Cleveland Clinic

1d • Remote

About The Position

At Cleveland Clinic Health System, we believe in a better future for healthcare. And each of us is responsible for honoring our commitment to excellence, pushing the boundaries and transforming the patient experience, every day. We all have the power to help, heal and change lives — beginning with our own. That’s the power of the Cleveland Clinic Health System team, and The Power of Every One. Join the Cleveland Clinic team, where you will work alongside passionate caregivers and provide patient-first healthcare. Cleveland Clinic is recognized as one of the top hospitals in the nation. At Cleveland Clinic, you will receive endless support and appreciation and build a rewarding career with one of the most respected healthcare organizations in the world. As a Utilization Review Nurse, you will provide clinical information to insurance companies to obtain authorization for future and elective surgeries, coordinate peer-to-peer reviews between insurance Medical Directors and Cleveland Clinic physicians and manage all pre-determination cases. This position primarily supports utilization review, with a strong focus on outpatient prior authorization requests. By taking this opportunity, you will join a fun, supportive, motivated, and detail-oriented team that is looking for a nurse with these qualities to join the team. A caregiver in this role works remotely from 8:00 a.m. – 4:30 p.m.

Requirements

• Graduate of an accredited practical/vocational or professional nursing program
• Current state licensure as a Licensed Practical Nurse (LPN) or Registered Nurse (RN)
• Two or more years of experience in coding or a patient care acute facility, preferably at a tertiary care medical center
• Excellent communications skills required to communicate will all levels in a health care environment

Nice To Haves

• Utilization Review experience
• Epic experience

Responsibilities

• Provide insurance companies with detailed clinical information when required to complete the authorization and pre-certification process.
• Communicate and attempt to resolve level of service discrepancies between CCF and insurance companies.
• Coordinate level of service justification directly with physician and communicate directly with third party payers to obtain approval.
• Complete responses on behalf of physician for denials.
• Review medical records and communicate with physicians to obtain authorization.
• Coordinate peer to peer reviews with CCF physicians and the insurance company Medical Director. Reviews are completed for CCF physicians at Main Campus and the community hospitals.
• Coordinate pre-determinations for specific procedures and maintain confidentiality of all patients' related information.
• Adhere to all JCAHO and Medicare compliance regulations.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed
• Number of Employees: 5,001-10,000 employees