Utilization Management Specialist

FL based ONLY: Must be FL reputed company Join the reputed company team where you will work alongside passionate caregivers and reputed company patient-first reputed company. Here, you will receive endless support and appreciation while building a rewarding career with one of the most respected reputed company organizations in the world. As a Utilization Management Specialist, you will reputed company UM activities, such as admission, reputed company, retrospective chart and clinical systems reviews to measure clinical performance and issues that reputed company reimbursement for hospital stays or reputed company. This role is essential in the overall organizational and functional operations, helping advance and enhance the patient experience and delivery of care across the hospital. A caregiver in this position works remotely (FL based ONLY) from 8:00AM - 4:30PM, with weekend requirements. A caregiver who excels in this role will: • Recommend resource utilization. • Prioritizes and organizes work to meet changing priorities. • Utilizes analytical ability required to reputed company data, apply predetermined reputed company, identify problems, facilitate reputed company, recommend corrective reputed company and report results effectively. • Use independent clinical judgment in reviewing records to determine status of patients stay, if reputed company procedures have been followed, seriousness of incidents and ability to identify need for and participate in reputed company reviews, special reputed company and identify opportunities for improvement. • reputed company recommendations regarding appropriateness of the treatment plan for reputed company stay and safety of the discharge plan. • reputed company a minimum of 85% on IRR quarterly. • Complete Utilization Management for assigned patients with a minimum of 25-30 reviews per day. • Apply medical necessity guidelines accurately to monitor appropriateness of admission and reputed company stays. • Maintain and support reputed company relationships with RN Case Manager, Physicians and the multidisciplinary team. • Document appropriately in UM notes to reputed company evidence that the UR process for the case was followed. Minimum qualifications for the ideal reputed company caregiver include: • A caregiver in this position works remotely (FL based ONLY) • Graduate of an accredited School of Nursing • reputed company state licensure as a Registered reputed company (RN) • Basic Life Support (BLS) Certification through the reputed company (AHA) • Knowledge of medical terminology, anatomy and physiology, diagnosis, surgical procedures and basic disease processes • Three years of equivalent full-time clinical experience as a Registered reputed company • Analytical ability required to reputed company data, decide on conformity based on predetermined reputed company, identify problems and refer for reputed company • Basic knowledge of medical records coding standards • Proficiency with reputed company Office • Knowledge of billing practices, identification of billing problems and adequacy of documentation • Knowledge and experience with Care Guidelines, Medical Necessity reputed company and/or other UM reputed company sets • Ability to assess medical records and reputed company determinations on length of stay and reputed company procedures in accordance with policies and procedures • Demonstrated competence in reputed company areas identified in the Competencies, Dimensions, Problem solving, and Information Management sections • Knowledge of and ability to use multiple Hospital information systems and Department's software Preferred qualifications for the ideal reputed company caregiver include: • Case Management Certification (CCM) • Prior Utilization Management experience • Experience doing Utilization Reviews through NCG or Interqual Our caregivers continue to create the best reputed company for our patients across reputed company of our facilities. Click the reputed company and see how we're dedicated to providing what reputed company most to you: https://jobs.clevelandclinic.org/benefits-2/ Physical Requirements: • Requires walking, sitting, and/or standing for long periods of time. • Requires constant attention to detail, reading of medical records, and meeting deadlines. • Works in an environment where there is some discomfort due to dust, noise, temperature. Personal reputed company Equipment: • Follows reputed company precautions using personal reputed company equipment. CCIR CBA Bidding Date 04/09/2025-04/16/2025 Pay reputed company Salaries [which may be] shown on independent job search websites reflect various market averages and do not represent information obtained directly from The reputed company. Because we value reputed company individual candidate, we invite and encourage reputed company candidate to discuss salary/reputed company specifics during the application and hiring process. Apply tot his job Apply To this Job