Founded in 1866, University Hospitals serves the needs of patients through an integrated network of 18 hospitals, more than 40 outpatient health centers and 200 physician offices in 15 counties throughout northern Ohio. The system's flagship academic medical center, University Hospitals Cleveland Medical Center, located on a 35-acre campus in Cleveland's University Circle, is affiliated with Case Western Reserve University School of Medicine. The main campus also includes University Hospitals Rainbow Babies & Children's Hospital, ranked among the top children's hospitals in the nation; University Hospitals MacDonald Women's Hospital, Ohio's only hospital for women; and University Hospitals Seidman Cancer Center, part of the NCI-designated Case Comprehensive Cancer Center. UH is home to some of the most prestigious clinical and research programs in the nation, including cancer, pediatrics, women's health, orthopedics, radiology, neuroscience, cardiology and cardiovascular surgery, digestive health, dermatology, transplantation and urology. UH Cleveland Medical Center is perennially among the highest performers in national ranking surveys, including 'America's Best Hospitals' from U.S. News & World Report. UH is also home to Harrington Discovery Institute at University Hospitals - part of The Harrington Project for Discovery & Development. UH is the second largest employer in northern Ohio with 26,000 employees. For more information, go to UHhospitals.org.
Minimum 3 years clinical (acute care) experience
Must have sound clinical knowledge base of the population to be served
Must be detail oriented and organized, with good analytical & problem solving ability
Notable client service, communication, presentation and relationship building skills
Ability to function independently and as a team player in a fast paced environment
Must have strong written and verbal communication skills
Demonstrated ability to use PCs, Microsoft Office and general office equipment
Demonstrated ability to apply concepts, utilize sound judgment and work independently within a framework of guidelines
Graduate of an accredited nursing program
Current RN licensure in the State of Ohio
Additional experience in sub-acute setting or managed care
Experience with Interqual or Miliman criteria
Knowledge of Medicare, Medicaid and commercial payer regulations
CM software proficiency
Collaborates and coordinates with all members of the health care team, patient and family (or significant others) to coordinate and ensure timely and efficient delivery of required workflow, services and tasks to result in:
Support of positive patient health care outcomes
Increased patient/health care team outcomes and satisfaction
Improved inpatient throughput and appropriate length of stay
Improved communication, awareness and adherence to regulatory requirements associated with utilization
Support for inappropriate level of care and decreased inpatient bed day denials
Continuity and coordination of care
Appropriate and timely authorization for level of care
Performs timely and accurate admission review, continued stay review and when appropriate support the peer to peer review process in accordance with department policy to ensure efficient use of hospital resources, timely discharge and optimal, appropriate reimbursement (includes communication with internal and external customers).
Collaborates and coordinates with all members of the health care team, patient and family (or significant others) to promote timely and effective communication, completion of workflow and services with regard to level of care decisions, regulatory requirements and payor decisions regarding continued stay.
Documents review activity, including but not limited to, application of criteria or policy as appropriate, clinical review to meet regulatory requirements and/or submit to insurance providers, initiation of registration changes when appropriate, outcomes and cost savings in a manner consistent with department requirements.
Meets department productivity and quality standards.
This role may encounter Protected Health Information (PHI) as part of regular responsibilities. UH employees must abide by all requirements to safely and securely maintain PHI for our patients. Annual training, the UH Code of Conduct and UH policies and procedures are in place to address appropriate use of PHI in the workplace.