Spectrum Health Utilization Review Specialist, RN (Priority Health) in Grand Rapids, Michigan
Facility: Priority Health - GRAND RAPIDS, MI
Department: Ph-Pre-Service Util Mgmt
Category: Registered Nurse
Classification: Full-time with Benefits (A1)
This position is responsible for providing a timely review of pre and post service authorization requests and appeals. Decisions will be made by utilizing clinical expertise, reviewing medical documentation, determining need and considering alternatives. This position will use InterQual Criteria, Medical Policies, Medicare Guidelines and plan documents to assist in making a determination. Case presentation will be made to the medical director for all complex requests and when medical criteria is not met for final determination.
Essential Job Functions:
Meet daily productivity standards of case review
Provide a clear case presentation to the medical director
Precise creation of Letters and Language associated with Authorization Requests
Provide quality clinical reviews of medical documentation
Appropriate application of Medical Policies and InterQual Criteria
Coordinating with healthcare providers to gain necessary information
Accurately enter data into complex computer systems for claims payment and reporting
Coordinate the peer to peer process with the physician or physician advisor
Comply with HIPAA/CMS regulations and the department policies and procedures.
Education - Associate's Degree in Nursing
Experience - 2 years of relevant experience in acute care, clinical nursing, preferably multiple clinical settings, or related experience
Registered Nurse (RN)
Education - Bachelor's Degree in Nursing
Spectrum Health grants equal employment opportunity to all qualified persons without regard to race, color, national origin, sex, disability, age, religion, genetic information, marital status, height, weight, sexual orientation, veteran status, or any other legally protected category.