Concurrent Denial Nurse BU - Utilization Management

Join the Cleveland Clinic team where you will work alongside passionate caregivers and provide patient-first healthcare. You will work alongside dedicated caregivers, receive endless support and appreciation, and build a rewarding career with one of the most respected healthcare organizations in the world.    

As a Concurrent Denial Nurse, you will support the Utilization Management Department by reviewing concurrent and retrospective clinical inpatient denials to ensure medical necessity criteria is met. We are looking for a Registered Nurse who is a subject matter expert in utilization management, has experience with MCG criteria, and is comfortable educating Caregivers and Physicians. In this role, you will get to work with a dynamic team of like-minded professionals and gain experience at an elite healthcare organization. 

A caregiver in this position works days from 7:30AM – 4:30PM. 

A caregiver who excels in this role will:  

• Serve as the expert in Utilization Management functions and be a resource to the department in general and the hospital. 

• Review and analyze concurrent and retrospective clinical denials and follow the specific payer processes. 

• Serve as an expert in payer specific process and communicate between payer and CCIRH to identify/resolve denial process issues. 

• Work in collaboration with the local physician advisor team and support the peer-to-peer process. 

• Perform the routine activities of a UM Specialist when needed while taking a leadership role. 

• Utilize knowledge of medical terminology, anatomy and physiology, diagnosis, surgical procedures and basic disease processes. 

• Utilize knowledge and experience with Care Guidelines and /or other UM criteria sets. 

• Utilize advanced interpersonal and communication written and verbal skills necessary to gather and exchange data (both internally and externally) with members of the health care team. 

• Recommend resource utilization when needed 

• Utilize analytical skills to gather data, identify problems and facilitate resolution. 

• Prioritize and organize work to meet changing priorities. 

• Utilize knowledge of multiple hospital information systems and department’s software. 

• Assist with education and monitoring of UM specialist's reviews. 

• Participate in payer specific p2p calls or local meetings as needed. 

Minimum qualifications for the ideal future caregiver include:  

• Completion of an accredited Registered Nursing Program (RN) 

• Bachelor’s Degree in Nursing or related field 

• Current valid license in the State of Florida as a Registered Nurse (RN) 

• Basic Life Support (BLS) certification through the American Heart Association (AHA) or American Red Cross 

• Three years of full-time Utilization Management experience 

• Demonstrated above average competence in Utilization Management Processes 

 
Preferred qualifications for the ideal future caregiver include:  

• Case Management certification (CCM or ACM)