Cleveland Clinic Utilization-Review-Nurse in Independence, Ohio

Job Summary:

Provides clinical information to insurance companies to ensure authorization is obtained to future/elective surgeries. Coordinates peer to peer with insurance Medical Directors and CCF physicians. Coordinates all Pre-determination cases.

Responsibilities:

  • Provides insurance company with detailed clinical information to when required to complete the authorization and pre-certification process.

  • Communicates and attempts to resolve level of service discrepancies between CCF and insurance companies.

  • Coordinates level of service justification directly with physician and communicates directly with third party payer to obtain approval.

  • Completes responses on behalf of physician for denials.

  • Reviews medical records and communicates with physician to obtain authorization.

  • Coordinates peer to peer reviews with CCF physician and insurance company Medical Director (reviews are completed for CCF physician at Main Campus and the Community Hospitals).

  • Coordinates pre-determinations for specific procedures as well as maintaining confidentiality of all patient related information.

  • Adheres to all JCAHO and Medicare compliance regulations.

  • Other duties as assigned.

Education:

  • Associate's degree in Nursing (Licensed Practical Nurse, Registered Nurse) or Health Information Technology.

Certifications:

  • Current state licensure as a Licensed Practical Nurse (LPN) or Registered Nurse (RN).

Complexity of Work:

  • Requires critical thinking skills, decisive judgment and the ability to work with minimal supervision.

  • Must be able to work in a stressful environment and take appropriate action.

Work Experience:

  • Two or more years of experience in coding or a patient care acute facility, preferably at a tertiary care medical center.

  • Excellent verbal and written communications skills required to communicate will all levels in a health care environment.

  • Excellent customer service, organizational skills along with ability to work under tight deadlines.

Physical Requirements:

  • Requires extensive sitting and dexterity to perform work on a PC.

  • Requires walking for extended periods of time.

  • Good visual acuity through normal or corrected vision.

  • Sedentary Work - Exerting up to 10 pounds of force occasionally (Occasionally: activity or condition exists up to 1/3 of the time) and/or a negligible amount of force frequently (Frequently: activity or condition exists from 1/3 to 2/3 of the time) to lift, carry, push, pull, or otherwise move objects, including the human body.

  • Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time.

  • Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.

Personal Protective Equipment:

  • Follows standard precautions using personal protective equipment as required.

The policy of Cleveland Clinic and its system hospitals (Cleveland Clinic) is to provide equal opportunity to all of our employees and applicants for employment in our tobacco free and drug free environment. All offers of employment are followed by testing for controlled substance and nicotine. Job offers will be rescinded for candidates for employment who test positive for nicotine. Candidates for employment who are impacted by Cleveland Clinic’s Smoking Policy will be permitted to reapply for open positions after 90 days. Decisions concerning employment, transfers and promotions are made upon the basis of the best qualified candidate without regard to color, race, religion, national origin, age, sex, sexual orientation, marital status, ancestry, status as a disabled or Vietnam era veteran or any other characteristic protected by law. Information provided on this application may be shared with any Cleveland Clinic facility.

Cleveland Clinic is pleased to be an equal employment employer: Women/Minorities/Veterans/Individuals with Disabilities