About Corewell Health

Our new name signals our bold commitment to health and wellness. At our core, we are here to help people be well so they can live their healthiest life possible. Through health care and health coverage, we create more value.​ Through compassion, collaboration, clarity, curiosity and courage, we make anything and everything possible.​ Through our people, we care for the whole person with respect, dignity and love. ​Everyone deserves opportunities and resources for better health.​ Everyone deserves our relentless pursuit to innovate and always do better. ​Everyone deserves to have a community be a great place to live, work, learn and play.​ We believe health and well-being should be within reach for all. We believe the system to support the entire health and wellness journey starts with prevention. ​We believe that together we will make a difference.​ Together, we are here to make health better for everyone.​ Together, we are Corewell Health.

Scope of work

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.Analyze the assessment data using clinical judgment to determine appropriate patient placement as well as to provide an accurate picture of the patient and his/her condition for all BH clinicians.

• 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.

How we will care for you, while you care for our patients

• Comprehensive benefits package to meet your financial, health, and work/life balance goals. Learn more here.
• 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

Qualifications

• Required Associate's Degree Associates or technical degree.
• Preferred Bachelor's Degree in nursing or related field.
• Hospital utilization review/utilization management experience. Preferred
• Clinical appeals experience. Preferred
• 2 years of relevant experience 2 years of experience in clinical/hospital setting. Required
• Registered Nurse (RN) - State of Michigan Upon Hire required