POSITION PORPOSE

The Utilization Review Specialist is responsible for facilitating collection of patient clinical information and application of clinical criteria considering clinical, age specific, developmental, cultural and spiritual needs. Facilitates utilization management documentation and appropriate communication with external agencies. Demonstrates area designated competencies.

Contingent position, scheduled every-other weekend.

WHAT YOU WILL DO

Performs concurrent and retrospective review of identified third party payor group medical records according to established criteria.

Exercises clinical judgment and objective application of Severity of Illness/Intensity of Service (SIIS) criteria in assessing patients' medical condition.

Maintains current knowledge of rules, regulations, policies, and procedures related to utilization management work processes and criteria.

Communicates information, in timely and complete manner, to third party payors as required for reimbursement purposes.

Communicates with appropriate health care team members and Patient Financial Services on cases requiring additional information pertaining to patients' medical status and progress when coverage issues arise.

Refers questionable cases and those not meeting criteria to Case Manager and for attending physician.

Identifies to Case Manager potential home care needs not yet identified, facilitating completion of home care planning as requested by Case Manager.

Supports Social Work & Case Management Department and patient care by providing coverage, sharing expertise, or proactively assisting with problem-solving, attending team meetings, and participating in ongoing program development.

MINIUMUM QUALIFICATIONS

Current Michigan Nursing License

Graduation from accredited nursing program (Effective January 1, 2013, all new hires must have a BSN degree or must agree in writing to obtain their BSN within five (5) years from date of hire.)

Experience: Three (3) years recent, related experience and clinically relevant knowledge regarding patient population.

ABOUT TRINITY HEALTH ANN ARBOR

Trinity Health Ann Arbor, a prestigious 537-bed teaching hospital, is situated on an expansive 340-acre campus and has proudly served as a top health care provider for over a century.

Honored as a Top 100 Hospital by Fortune/IBM Watson, our institution is part of the renowned Trinity Health Michigan network.

Our numerous local and national awards acknowledge our unwavering commitment to leadership, quality outcomes, and clinical excellence.

Our Commitment to Diversity and Inclusion
 

Trinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and inclusion in all that we do. Our colleagues have different lived experiences, customs, abilities, and talents. Together, we become our best selves. A diverse and inclusive workforce provides the most accessible and equitable care for those we serve. Trinity Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by law.