• Review acute and post-acute authorizations for medical necessity using InterQual guidelines • Collaborate with case managers, physicians, and medical directors to ensure appropriate levels of care • Participate in team meetings, educational activities, and interrater reliability testing to maintain review consistency and professional growth • Ensure compliance with federal, state, and accreditation standards, and identify opportunities to enhance communication or processes • Utilize knowledge of resources available in the healthcare system to assist physicians and patients effectively • Perform other job duties as assigned

• Perform clinical reviews of medical records and other documentation to validate issues of claims coding accuracy, medical necessity, and the appropriateness of treatment settings and services delivered. • Report to the Payment Assurance Senior Manager and support a culture and work environment that promotes and inspires an active, continuous improvement philosophy regarding products and services in line with our company mission. • Audits and analyzes neonatal intensive care unit (NICU) claims according to ICD-10 coding principles and clinical guidelines. • Analysis of claims data to optimize reimbursement by ensuring that the diagnosis codes, procedure codes, and supporting documentation accurately support the service rendered. • Ensure claims analysis complies with ethical coding standards, guidelines, and regulatory requirements. • Responsible for performing clinical reviews of medical records and other documentation to validate issues of claims coding accuracy, medical necessity, and the appropriateness of treatment settings and services delivered. • Utilize Clinical Review Tools and EMR Systems. • Research reimbursement regulations for claim payment compliance to support and validate audit findings. • Assist with the development of claims audit process documentation, including workflow diagrams, policies and procedures, and standard operating procedures. • Detect discrepancies in provider billing and recommend adjustments to ensure proper reimbursement.

Title: PRN Utilization Management RN Reviewer NE Location: Weston United States Job 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 and 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 and 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 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 meeting when scheduled to work. - Other duties as assigned. Minimum qualifications for the ideal future caregiver include: - 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 Preferred qualifications for the ideal future caregiver include: - Bachelor of science in nursing (BSN) - 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. Pay Range Salaries [which may be] shown on independent job search websites reflect various market averages and do not represent information obtained directly from The Cleveland Clinic. Because we value each individual candidate, we invite and encourage each candidate to discuss salary/hourly specifics during the application and hiring process.

• Performs medical claim reviews for claims for medically complex services • Services that require preauthorization/predetermination • Requests for appeal or reconsideration • Referrals for potential fraud and/or abuse • Correct coding for claims/operations • Makes reasonable charge payment determinations based on clinical/medical information and established criteria/protocol sets • Determines medical necessity and appropriateness and/or reasonableness and necessity for coverage and reimbursement • Documents medical rationale to justify payment or denial of services and/or supplies • Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. • Participates in quality control activities in support of the corporate and team-based objectives • Provides guidance, direction, and input as needed to LPN team members • Provides education to non-medical staff through discussions, team meetings, classroom participation and feedback • Assists with special projects and specialty duties/responsibilities as assigned by Management