• Review medical records to determine the medical necessity of a request for medical services. • Validate diagnosis and corresponding algorithms of care. • Evaluate for over-utilization of treatment requests inconsistent with evidence based guidelines. • Communicate with the claims examiner, providers, and any other auxiliary provider regarding UR determination. • Summarize medical records and all pertinent information for Physician Advisor. • Identify the need for medical case management and make recommendations for referral through supervisor.

Role Description The Clinical Guide Part A will be part of the Utilization Management team, responsible for inpatient, behavioral health, and/or post-acute authorization review in alignment with CMS and Medicare Advantage regulations. - Reviews medical records to evaluate the medical necessity and appropriateness of requested inpatient and/or post-acute services in accordance with established clinical criteria and CMS guidelines. Your Responsibilities and Impact will include: - Review Medical Records: Conduct prospective (pre-service), concurrent, and retrospective utilization review to evaluate medical necessity, appropriate level of care (Inpatient vs. Observation), and post-acute services in accordance with established clinical criteria and CMS guidelines. - Evaluate Treatment Plans: Assess the appropriateness, timing, and setting of requested services, ensuring alignment with medical necessity criteria and Medicare Advantage requirements. Recommend alternative levels of care when clinically appropriate. - Inpatient & Behavioral Health Review: Perform initial, concurrent, and discharge reviews for inpatient and behavioral health admissions. Ensure admission status accuracy and regulatory compliance with CMS timeliness (TAT) standards. - Post-Acute Review: Conduct initial authorization and concurrent review for post-acute services (SNF, LTACH, ARU, Home Health), evaluating ongoing medical necessity and appropriate length of stay. Issue NOMNC when coverage criteria are no longer met. - Medical Director Collaboration: Refer cases that do not meet criteria to the Medical Director for secondary review and final determination. Prepare clinical summaries and coordinate peer-to-peer (P2P) discussions. Manage authorization reopen requests as appropriate. - Resource Stewardship: Monitor utilization of inpatient and post-acute services to promote appropriate resource use while maintaining high-quality, member-centered care. - Regulatory & Documentation Compliance: Maintain accurate, defensible documentation of all determinations. Ensure adherence to CMS regulations, Medicare Advantage requirements, and internal compliance standards. Qualifications - Unrestricted RN license with a minimum of 4 years of clinical experience. - Minimum 3 years of Utilization Management or Inpatient UR experience within a health plan or hospital setting. - Strong knowledge of CMS regulations and Medicare Advantage requirements. - Experience preparing cases for Medical Director review. - Able to work in a fast paced environment that is constantly evolving. Requirements - Experience with AI/LLM. - Certified in InterQual. Benefits - Employer sponsored health, dental and vision plan with low or no premium. - Generous paid time off. - $100 monthly mobile or internet stipend. - Stock options for all employees. - Bonus eligibility for all roles excluding Director and above; Commission eligibility for Sales roles. - Parental leave program. - 401K program. - And more....

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