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Job TitleUtilization Management Specialist
LocationCleveland
FacilityRemote Location
DepartmentNRS-Enterprise Utilization Mgmt-Nursing Institute
Job Code0008IR
ShiftDays
Schedule8:00am-4:30pm
Job Summary
Job Details
FL based ONLY: Must be FL resident
Join the Cleveland Clinic team where you will work alongside passionate caregivers and provide patient-first healthcare. Here, you will receive endless support and appreciation while building a rewarding career with one of the most respected healthcare organizations in the world.
As a Utilization Management Specialist, you will perform UM activities, such as admission, concurrent, retrospective chart and clinical systems reviews to measure clinical performance and issues that affect reimbursement for hospital stays or visits. This role is essential in the overall organizational and functional operations, helping advance and enhance the patient experience and delivery of care across the hospital.
A caregiver in this position works remotely (FL based ONLY) from 8:00AM - 4:30PM, with weekend requirements.
A caregiver who excels in this role will:
- Recommend resource utilization.
- Prioritizes and organizes work to meet changing priorities.
- Utilizes analytical ability required to gather data, apply predetermined criteria, identify problems, facilitate resolution, recommend corrective action and report results effectively.
- Use independent clinical judgment in reviewing records to determine status of patients stay, if proper procedures have been followed, seriousness of incidents and ability to identify need for and participate in focused reviews, special projects and identify opportunities for improvement.
- Make recommendations regarding appropriateness of the treatment plan for continued stay and safety of the discharge plan.
- Achieve a minimum of 85% on IRR quarterly.
- Complete Utilization Management for assigned patients with a minimum of 25-30 reviews per day.
- Apply medical necessity guidelines accurately to monitor appropriateness of admission and continued stays.
- Maintain and support collaborative relationships with RN Case Manager, Physicians and the multidisciplinary team.
- Document appropriately in UM notes to provide evidence that the UR process for the case was followed.
Minimum qualifications for the ideal future caregiver include:
- A caregiver in this position works remotely (FL based ONLY)
- Graduate of an accredited School of Nursing
- Current state licensure as a Registered Nurse (RN)
- Basic Life Support (BLS) Certification through the American Heart Association (AHA)
- Knowledge of medical terminology, anatomy and physiology, diagnosis, surgical procedures and basic disease processes
- Three years of equivalent full-time clinical experience as a Registered Nurse
- Analytical ability required to gather data, decide on conformity based on predetermined criteria, identify problems and refer for resolution
- Basic knowledge of medical records coding standards
- Proficiency with Microsoft Office
- Knowledge of billing practices, identification of billing problems and adequacy of documentation
- Knowledge and experience with Care Guidelines, Medical Necessity Criteria and/or other UM criteria sets
- Ability to assess medical records and make determinations on length of stay and proper procedures in accordance with policies and procedures
- Demonstrated competence in all areas identified in the Competencies, Dimensions, Problem solving, and Information Management sections
- Knowledge of and ability to use multiple Hospital information systems and Department's software
Preferred qualifications for the ideal future caregiver include:
- Case Management Certification (CCM)
- Prior Utilization Management experience
- Experience doing Utilization Reviews through NCG or Interqual
Our caregivers continue to create the best outcomes for our patients across each of our facilities. Click the link and see how we’re dedicated to providing what matters most to you: https://jobs.clevelandclinic.org/benefits-2/
Physical Requirements:
- Requires walking, sitting, and/or standing for long periods of time.
- Requires constant attention to detail, reading of medical records, and meeting deadlines.
- Works in an environment where there is some discomfort due to dust, noise, temperature.
Personal Protective Equipment:
- Follows standard precautions using personal protective equipment.
CCIR CBA Bidding Date 04/09/2025-04/16/2025
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.
Please review the Equal Employment Opportunity poster.
Cleveland Clinic Health System is pleased to be an equal employment employer: Women / Minorities / Veterans / Individuals with Disabilities
Top Skills
What We Do
Cleveland Clinic, located in Cleveland, Ohio, is a not-for-profit, multispecialty academic medical center that integrates clinical and hospital care with research and education.
Founded in 1921 by four renowned physicians with a vision of providing outstanding patient care based upon the principles of cooperation, compassion and innovation, Cleveland Clinic has become one of the largest and most respected hospitals in the country.
Cleveland Clinic facilities can be found throughout Northeast Ohio, as well as around the country and world including:
Cleveland Clinic Florida
Cleveland Clinic Canada
Cleveland Clinic Abu Dhabi
Cleveland Clinic Lou Ruvo Center for Brain Health - Las Vegas
Cleveland Clinic health system includes eight regional hospitals, 16 family health centers, a children's hospital for rehabilitation and one affiliate hospital. Cleveland Clinic is accredited by The Joint Commission, the nation’s largest accreditor of healthcare organizations.
Our family health centers offer:
Outpatient care
Primary care
Numerous subspecialties
Numerous locations
All of our hospitals, family health centers, outpatient clinics and home healthcare programs are also accredited by The Joint Commission under its hospital accreditation program.
