Utilization Management Specialist

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.

FL based ONLY: Must be FL resident 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 Specialist, you will perform UM activities, such as admission, concurrent, retrospective chart and clinical systems reviews to measure clinical performance and issues that affect reimbursement for hospital stays or visits. This role is essential in the overall organizational and functional operations, helping advance and enhance the patient experience and delivery of care across the hospital. A caregiver in this position works remotely (FL based ONLY) from 8:00AM – 4:30PM, with weekend requirements.

Recommend resource utilization. Prioritizes and organizes work to meet changing priorities. Utilizes analytical ability required to gather data, apply predetermined criteria, 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. Maintain and support collaborative relationships with RN Case Manager, Physicians and the multidisciplinary team. Document appropriately in UM notes to provide evidence that the UR process for the case was followed.