Utilization Review Nurse – Employee Health Plan (EHP)

At Cleveland Clinic Health System, we believe in a better future for healthcare. And each of us is responsible for honoring our commitment to excellence, pushing the boundaries and transforming the patient experience, every day.

We all have the power to help, heal and change lives — beginning with our own. That’s the power of the Cleveland Clinic Health System team, and The Power of Every One.

Job Title

Utilization Review Nurse – Employee Health Plan (EHP)

Location

Independence

Facility

Independence West Creek

Department

Clinical Integration Health Plan Management-Finance

Job Code

T24041

Shift

Days

Schedule

8:00am-4:30pm

Job Summary

Job Details

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 and manage all pre-determination cases. This position primarily supports utilization review, with a strong focus on outpatient prior authorization requests. By taking this opportunity, you will join a fun, supportive, motivated, and detail-oriented team that is looking for a nurse with these qualities to join the team.

A caregiver in this role works remotely from 8:00 a.m. – 4:30 p.m.

Position requires residency 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 physician and communicate directly with third party payers to obtain approval.
• Complete responses on behalf of physician 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. Reviews are completed for CCF physicians at Main Campus and the community hospitals.
• Coordinate pre-determinations for specific procedures and maintain confidentiality of all patients’ related information.
• Adhere to all JCAHO and Medicare compliance regulations.

Minimum qualifications for the ideal future caregiver include:

• 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 communications skills required to communicate will all levels in a health care environment

Preferred qualifications for the ideal future caregiver include:

• Utilization Review experience
• Epic experience

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 Health System and its system hospitals (Cleveland Clinic Health System) is to provide equal opportunity to all of our caregivers and applicants for employment in our drug free environment. All offers of employment are followed by testing for controlled substances.

Cleveland Clinic Health System administers an influenza prevention program. You will be required to comply with this program, which will include obtaining an influenza vaccination on an annual basis or obtaining an approved exemption.

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 Health System facility.

If applying for a Florida position, please see the following website for more information on the background screening requirements required by the Agency of Health Care Administration: https://info.flclearinghouse.com/

Please review the Equal Employment Opportunity poster.

Cleveland Clinic is pleased to be an equal employment opportunity employer.