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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:

  1. Meet daily productivity standards of case review

  2. Provide a clear case presentation to the medical director

  3. Precise creation of Letters and Language associated with Authorization Requests

  4. Provide quality clinical reviews of medical documentation

  5. Appropriate application of Medical Policies and InterQual Criteria

  6. Coordinating with healthcare providers to gain necessary information

  7. Accurately enter data into complex computer systems for claims payment and reporting

  8. Coordinate the peer to peer process with the physician or physician advisor

  9. Comply with HIPAA/CMS regulations and the department policies and procedures.

Basic Qualifications:

Education - Associate's Degree in Nursing

Experience - 2 years of relevant experience in acute care, clinical nursing, preferably multiple clinical settings, or related experience

Licenses -

Registered Nurse (RN)

Preferred Qualifications:

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.