[Hiring] Utilization Review Nurse - Employee Health Plan @Cleveland Clinic

Role Description Join the Cleveland Clinic team, where you will work alongside passionate caregivers and provide patient-first healthcare. Cleveland Clinic is recognized as one of the top hospitals in the nation. At Cleveland Clinic, you will receive endless support and appreciation and build a rewarding career with one of the most respected healthcare organizations in the world. As a Utilization Review Nurse, you will: • Provide clinical information to insurance companies to obtain authorization for future and elective surgeries. • Coordinate peer-to-peer reviews between insurance Medical Directors and Cleveland Clinic physicians. • Manage all pre-determination cases, primarily supporting utilization review with a strong focus on outpatient prior authorization requests. • Work remotely from 8:00 a.m. – 4:30 p.m. • Be required to reside in northeast Ohio. A caregiver who excels in this role will: • Provide insurance companies with detailed clinical information when required to complete the authorization and pre-certification process. • Communicate and attempt to resolve level of service discrepancies between CCF and insurance companies. • Coordinate level of service justification directly with physicians and communicate directly with third-party payers to obtain approval. • Complete responses on behalf of physicians for denials. • Review medical records and communicate with physicians to obtain authorization. • Coordinate peer-to-peer reviews with CCF physicians and the insurance company Medical Director. • Coordinate pre-determinations for specific procedures and maintain confidentiality of all patients' related information. • Adhere to all JCAHO and Medicare compliance regulations. Qualifications • Graduate of an accredited practical/vocational or professional nursing program. • Current state licensure as a Licensed Practical Nurse (LPN) or Registered Nurse (RN). • Two or more years of experience in coding or a patient care acute facility, preferably at a tertiary care medical center. • Excellent communication skills required to communicate with all levels in a healthcare environment. Requirements • Utilization Review experience (preferred). • Epic experience (preferred). Benefits • Follows standard precautions using personal protective equipment as required. • Participation in an influenza prevention program, including obtaining an annual influenza vaccination or an approved exemption. Apply tot his job Apply To this Job