Role Description Assumes responsibility for assessing a patient's clinical status on admission and daily to determine the appropriate admission status type and level of care. Refers cases to the physician advisor, PA moonlighter, for a second level review as needed. Facilitates communication with service based multidisciplinary team as it relates to the patient and identified treatment plan. Works in accordance to established policies and procedures to ensure optimal patient outcomes. Has the ability to work with variable service lines and with multiple care teams. Qualifications - Minimum of 3 years of acute care nursing experience is required. - Prior utilization management or case management experience is required. - A minimum of 5 years of acute care nursing experience is preferred. - Utilization of Interqual, MCG care web QI or Indicia evidence based guidelines is strongly preferred. - Professional knowledge of nursing theory and practice at a level normally acquired through completion of a program at an accredited School of Nursing is required. - Bachelor's Degree in Nursing is preferred. - Knowledge of Medicare inpatient only surgical list, Medicare guidelines for admission, working DRG, and some familiarity with hospital coding is preferred. - Requires current state of Wisconsin Registered Nurse License or a Multi-state Nursing License from a participating state in the NLC (Nurse Licensure Compact). - MCG certification is required within 18 months of hire. - Accredited Case Manager (ACM) or Certified Case Manager (CCM) certification preferred. Benefits - Pay is expected to be between: $34.00 - $52.70 (hourly). - Paid time off. - Growth opportunity - Career Pathways & Career Tuition Assistance, CEU opportunities. - Academic Partnership with the Medical College of Wisconsin. - Referral bonuses. - Retirement plan - 403b. - Medical, Dental, Vision, Life Insurance, Short & Long Term Disability, Free Workplace Clinics. - Employee Assistance Programs, Adoption Assistance, Healthy Contributions, Care@Work, Moving Assistance, Discounts on gym memberships, travel and other work life benefits available. Company Description The Froedtert & the Medical College of Wisconsin regional health network is a partnership between Froedtert Health and the Medical College of Wisconsin supporting a shared mission of patient care, innovation, medical research and education. Our health network operates eastern Wisconsin's only academic medical center and adult Level I Trauma center engaged in thousands of clinical trials and studies. The Froedtert & MCW health network, which includes ten hospitals, nearly 2,000 physicians and more than 45 health centers and clinics draw patients from throughout the Midwest and the nation.

• maximize the quality and cost-efficiency of health care services at ProMedica • complete reviews for admissions and transfers • apply payer rules to obtain authorizations • work with physicians, nurses, and other members of the health care team • review cases and look for opportunities to improve hospital service utilization

• RN Clinician responsible for utilization management services within the scope of licensure. • Conducts primary functions of prior authorization, inpatient review, concurrent review, retrospective review, medical director referrals and execution of member/provider approval and/or denial letter. • Reviews provider requests for services requiring authorization. • Conducts pre-certification, continued stay review, care coordination, or discharge planning for appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts. • May manage appeals for services denied. • Responsible for written and/or verbal notification to members and providers. • Demonstrates proactive anticipatory discharge planning; serves as joint transition of care coordinator with case management and facilitates member care transition. • Ensures medical director written decision is consistent with criteria (CMS, state, medical policy, clinical criteria). • Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards.