Utilization Management RN Reviewer

Cleveland Clinic, located in Cleveland, Ohio, is a not-for-profit, multispecialty academic medical center that integrates clinical and hospital care with research and education. Founded in 1921 by four renowned physicians with a vision of providing outstanding patient care based upon the principles of cooperation, compassion and innovation, Cleveland Clinic has become one of the largest and most respected hospitals in the country.

**This is a remote position for applicants currently residing in Ohio Join the Cleveland Clinic team where you will work alongside passionate caregivers and provide patient-first healthcare. Here, you will receive endless support and appreciation while building a rewarding career with one of the most respected healthcare organizations in the world. As a Utilization Management (UM) RN Reviewer supporting all inpatient units, you will play a key role in ensuring quality care and appropriate resource utilization for patients while supporting reimbursement processes. In this role, you’ll conduct admission, concurrent, and retrospective reviews of charts and clinical systems, provide clinical information to payers, and contribute to UM data collection, reporting, and appeals. You will collaborate closely with physicians and enterprise advisors, ensuring compliance with regulatory guidelines and advocating for patients through accurate, timely clinical reviews. This position offers a unique opportunity to make a meaningful impact on patient care while strengthening your analytical, critical thinking, and communication skills in a highly collaborative environment. This is a remote position, caregivers may occasionally work on-site at a designated facility. A caregiver in this position works 8:00am to 4:30pm with some varying shift times. Weekend requirements include inpatient observation/recovery every 4 weeks. Holiday requirements include 1 per year.

Recommend resource utilization. Utilize analytical ability 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 a minimum of 25-30 reviews per day. Apply medical necessity guidelines accurately to monitor appropriateness of admission and continued stays. Follow department guidelines on escalation processes and refer cases appropriately to the internal or external PA. Maintain professional work standards including confidentiality, ethical principles, and professional work habits. Maintain and support collaborative relationships with TCC's, physicians and the multidisciplinary team. Document appropriately in UM notes to provide evidence that the UR process for the case was followed. Design and initiate special projects as supervised by the Team Manager.