[Hiring] Utilization Review Nurse - Employee Health Plan @Cleveland Clinic
Role Description
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:
ā¢ Provide clinical information to insurance companies to obtain authorization for future and elective surgeries.
ā¢ Coordinate peer-to-peer reviews between insurance Medical Directors and Cleveland Clinic physicians.
ā¢ Manage all pre-determination cases, primarily supporting utilization review with a strong focus on outpatient prior authorization requests.
ā¢ Work remotely from 8:00 a.m. ā 4:30 p.m.
ā¢ Be required to reside in northeast Ohio.
A caregiver who excels in this role will:
ā¢ Provide insurance companies with detailed clinical information when required to complete the authorization and pre-certification process.
ā¢ Communicate and attempt to resolve level of service discrepancies between CCF and insurance companies.
ā¢ Coordinate level of service justification directly with physicians and communicate directly with third-party payers to obtain approval.
ā¢ Complete responses on behalf of physicians for denials.
ā¢ Review medical records and communicate with physicians to obtain authorization.
ā¢ Coordinate peer-to-peer reviews with CCF physicians and the insurance company Medical Director.
ā¢ Coordinate pre-determinations for specific procedures and maintain confidentiality of all patients' related information.
ā¢ Adhere to all JCAHO and Medicare compliance regulations.
Qualifications
ā¢ Graduate of an accredited practical/vocational or professional nursing program.
ā¢ Current state licensure as a Licensed Practical Nurse (LPN) or Registered Nurse (RN).
ā¢ Two or more years of experience in coding or a patient care acute facility, preferably at a tertiary care medical center.
ā¢ Excellent communication skills required to communicate with all levels in a healthcare environment.
Requirements
ā¢ Utilization Review experience (preferred).
ā¢ Epic experience (preferred).
Benefits
ā¢ Follows standard precautions using personal protective equipment as required.
ā¢ Participation in an influenza prevention program, including obtaining an annual influenza vaccination or an approved exemption.
Apply tot his job
Apply To this Job
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:
ā¢ Provide clinical information to insurance companies to obtain authorization for future and elective surgeries.
ā¢ Coordinate peer-to-peer reviews between insurance Medical Directors and Cleveland Clinic physicians.
ā¢ Manage all pre-determination cases, primarily supporting utilization review with a strong focus on outpatient prior authorization requests.
ā¢ Work remotely from 8:00 a.m. ā 4:30 p.m.
ā¢ Be required to reside in northeast Ohio.
A caregiver who excels in this role will:
ā¢ Provide insurance companies with detailed clinical information when required to complete the authorization and pre-certification process.
ā¢ Communicate and attempt to resolve level of service discrepancies between CCF and insurance companies.
ā¢ Coordinate level of service justification directly with physicians and communicate directly with third-party payers to obtain approval.
ā¢ Complete responses on behalf of physicians for denials.
ā¢ Review medical records and communicate with physicians to obtain authorization.
ā¢ Coordinate peer-to-peer reviews with CCF physicians and the insurance company Medical Director.
ā¢ Coordinate pre-determinations for specific procedures and maintain confidentiality of all patients' related information.
ā¢ Adhere to all JCAHO and Medicare compliance regulations.
Qualifications
ā¢ Graduate of an accredited practical/vocational or professional nursing program.
ā¢ Current state licensure as a Licensed Practical Nurse (LPN) or Registered Nurse (RN).
ā¢ Two or more years of experience in coding or a patient care acute facility, preferably at a tertiary care medical center.
ā¢ Excellent communication skills required to communicate with all levels in a healthcare environment.
Requirements
ā¢ Utilization Review experience (preferred).
ā¢ Epic experience (preferred).
Benefits
ā¢ Follows standard precautions using personal protective equipment as required.
ā¢ Participation in an influenza prevention program, including obtaining an annual influenza vaccination or an approved exemption.
Apply tot his job
Apply To this Job