Utilization Review Nurse

Utilization Review Specialist

Cleveland, OH (on-site)

$40-43/HR

8:30 am-5 pm (M-F)

The UR Specialist plays a critical role in coordinating resident assessments, care planning, utilization review, reimbursement, and interdisciplinary communication to ensure high-quality, cost-effective resident care while maintaining compliance with state and federal regulations.

UR Specialist Responsibilities:

• Coordinate and oversee completion of MDS 3.0 assessments and comprehensive resident care plans.
• Complete assessments for newly admitted residents and residents experiencing significant changes in condition.
• Review interdisciplinary documentation to ensure accurate and complete resident assessments.
• Maintain compliance with CMS, Medicare, Medicaid, State of Ohio, and federal documentation requirements.
• Attend utilization review meetings and collaborate with interdisciplinary teams regarding resident eligibility and insurance coverage.
• Monitor Medicare and managed care benefits, including tracking Medicare benefit days.
• Promote resident rights, dignity, privacy, and confidentiality.

UR Specialist Qualifications:

• Current, valid, and unrestricted LPN or RN license in OH is preferred but not required.
• Previous MDS coordination and utilization review experience in a skilled nursing or long-term care setting.
• Experience with managed care authorization processes.
• Strong clinical assessment skills.
• Flexibility to work occasional evenings, weekends, or additional hours as needed.
• Knowledge of:
• Medicare
• Medicaid
• PPS reimbursement
• Subacute/skilled nursing care