• Assists with data collection, entry and generation of reports • Coordinates communication between Patient Financial Services, Third party Payers, patients, and physicians • Performs certifications, authorizations, concurrent reviews, and appeals • Reviews inpatient and observation patients for Medicare, Medicaid, Commercial, and Medicare HMO third party payers.

Role Description Join Cleveland Clinic Weston Hospital’s team of caregivers that remain on the leading edge of technology and education, all while consistently providing patient-centered healthcare. As part of Cleveland Clinic’s Florida region, Weston Hospital is recognized as one of the top hospitals in the Miami-Fort Lauderdale and Florida regions. Here, you will receive endless support and appreciation while building a rewarding career with one of the most respected healthcare organizations in the world. Utilization Management (UM) Specialists perform UM activities, such as: - Admission review - Concurrent review - Retrospective chart review - Clinical systems review to measure clinical performance and UM issues that affect reimbursement for the patient’s hospital stay or visit Some of the responsibilities of a Utilization Management Specialist include: - Medical record review - Providing clinical information to payers - UM data collection and reporting - Concurrent denials appeals process - Clinical team interaction - Physician Adviser interaction - Special projects This is a regular PRN position, with caregivers working days between 8:00 a.m. – 4:30 p.m. with weekend requirements. This remote role is limited to Florida, Ohio, and Nevada. Candidates must live within one hour of a Cleveland Clinic hospital to be eligible. A caregiver who excels in this role will: - Recommend resource utilization - Prioritize and organize work to meet changing priorities - Utilize analytical abilities required to gather data - Use clinical judgment to apply predetermined criteria or use independent clinical judgment when no predetermined criteria exist to 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 the 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 at least 25-30 reviews per day - Apply medical necessity guidelines accurately to monitor appropriateness of admission and continued stays - Document appropriately in UM notes to provide evidence that the UR process for the case was followed - Attend all staff meetings when scheduled to work - Other duties as assigned Qualifications - 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) or American Red Cross - Three years of equivalent full-time clinical experience as a Registered Nurse - Knowledge of medical terminology, anatomy and physiology, diagnosis, surgical procedures, and basic disease processes - Analytical ability to gather data, decide on conformity based on predetermined criteria, identify problems and refer for resolution - Basic knowledge of medical records coding standards - Awareness of licensing and accreditation standards - Proficient with Microsoft Office - Knowledge of billing practices, identification of billing problems, adequacy of documentation, and ability to conduct research of issue at hand, as well as formulate recommendations based on findings - 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 - Knowledge of and ability to use multiple Hospital information systems and Department's software - Ability to use copier, fax machine and personal computer Requirements - Bachelor of science in nursing (BSN) preferred - Case Management Certification (CCM) preferred within first year of eligibility - Prior Utilization Management experience - Case management or ED experience 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. Company Description 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. 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.

• Responsible for making medical records audit payment decisions on a wide variety of claim complexities within department standards • Responsible for researching, analyzing, and making audit payment decisions on moderately complicated claims based on medical coding guidelines and policies • Refer suspected Fraud, Waste, or Abuse to the SIU when identified in normal course of business • Responsible for meeting productivity standards while maintaining quality as outlined in SOP • Responsible for identifying and implementing process improvements and referring system enhancement ideas to manager • Collaborates with internal departments to facilitate claim processing and to come to appropriate claim resolutions • Responds to simple escalation and provider inquiries • Prepares claim audit summaries for Medical Director review by completing required documentation and ensuring all pertinent medical information is attached as needed • Ensure adherence to all company and departmental policies and standards for timeliness of review and release of claims • Responsible for identifying systemic and process issues problems/concerns and reporting them to management • Responsible for backing up administrative duties in medical record acquisition processes • Responsible for identification of training and quality areas to be shared with management • Perform any other job related duties as requested

Title: Coding Quality Reviewer Location: Nashville, Tennessee, United States Job Description: As a Coding Quality Review (CQR) Specialist, you will operate in a work from home environment supporting all CQR team related systems and tools. You will perform internal quality assessment reviews on Health Information Management Service Center(HSC) coders to ensure compliance with national coding guidelines, the HSC coding policies and the Company coding policies for complete, accurate and consistent coding which result in appropriate reimbursement and data integrity. Job Responsibilities - Lead, coordinate and perform all functions of quality reviews (routine, pre-bill, policy driven and incentive plan driven)for inpatient and outpatient coding across multiple HSCs - Assist in ensuring HSC coding staff adherence with coding guidelines and policy - Demonstrate and apply expert level knowledge of medical coding practices and concepts - Participate on special reviews or projects - Maintain or exceed 95% productivity standards - Maintain or exceed 95% accuracy - Meet all educational requirements as stated in current Company policy - Review all official data quality standards, coding guidelines, Company policies and procedures, and clinical/medical resources to assure coding knowledge and skills remain current Qualifications - Undergraduate degree in HIM/HIT preferred (Associate's or Bachelor's) - RHIA, RHIT and/or mandatory - IP Coding Auditor for MS-DRG - Must have experience in all body systems – cannot be specialized in one area i.e., Orthopedic etc. - Must have 3 years of hands on coding MS-DRG auditing in a hospital setting. - Cannot be a recent graduate needs experience ideally 10+ years of coding and 3 years of auditing in MS-DRG Inpatient medical records. We cannot employee candidates who reside in California, Alaska, New York or Colorado for any of our work from home positions Will be expected to complete a coding test (20 Multiple Choice/True/False 5-7 Open ended Behavioral questions- 90 minutes long Additional information - FTE’s-4