Utilization Review Coordinator RN

MyMichigan Health is a partnership of health providers, services and facilities in the heart of Michigan. It is a non-profit, tax-exempt health system affiliated with the University of Michigan Health. As a non-profit, all excess revenues go back into providing care, upgrading services, fairly compensating employees and creating a supportive work environment. The quality of its medical facilities and campuses have been enhanced by the generosity of local foundations and donors. Serving more than one million residents in a 26-county region, MyMichigan Health acts as a parent organization with various joint ventures and management contracts. In fiscal year 2025, MyMichigan Health provided $243 million in community benefits and other uncompensated care. MyMichigan also contributes significantly to the health of its local economies. Listed by Forbes among ‘America’s Best Employers by State’ for four consecutive years from 2022 to 2025, as well as named to Forbes’ list of ‘America’s Best Employers for Healthcare Professionals’ in 2025, MyMichigan is a major employer in all the areas it serves with employees having earned $815 million in wages and $147 million in benefits in fiscal year 2025.

This position plays a pivotal role in maintaining the fiscal health of the organization by ensuring the organization is fully reimbursed. Educating and consulting with the physician and the health care team to ensure accuracy of medical necessity criteria and to ensure timely and appropriate level of care is achieved. This requires excellent time management and prioritization skills along with collaboration with the provider and case management teams.

(30%)* Performs admission, concurrent and focused reviews using the medical necessity criteria and complies with CMS requirements. Perform admission/continued stay/discharge reviews when applicable. (30%)* Determines necessity of second-level review and implement process per hospital policy. Provide educational information to physicians and other staff members as appropriate regarding medical necessity criteria, documentation guidelines, admission status, etc. and collaborates with the care team. (15%)* Assist UR Committee and subcommittees in identifying areas of mis-utilization. Perform Hospital- wide quality assurance activities as requested. (15%)* Facilitate appropriate insurance pre-certification, appropriate admission and status of patient. Successfully negotiates patient status with the payer. (10%)* Attend and participate in case management and discharge planning as required. Other Duties And Responsibilities Complete denial appeals with physician and additional chart information, coordinate information and send in appeal. Coordinate with Appeals RN, as needed. Maintain documentation of reviews, telephone contacts, appeal activity and progress. Provides pertinent clinical data to designated outside agencies to assure compliance with their requirements. Participates in Continuous Quality Improvement as required by the Medical Center and the job description. Is skilled in determining the need for and implementing the hospital notice of non coverage. Understands and is accountable for the Health System's customer service standards.