The Utilization Review (UR) Nurse ensures services meet member's health needs and promotes the provision of high quality care in the most appropriate and cost-effective setting by identifying, assessing, planning, coordinating, monitoring, and evaluating healthcare services, outcomes, and managing the utilization of Health Alliance Plan (HAP) benefits through activities of medical utilization review and discharge planning. This individual promotes collaboration with the patient care team, such as the Outpatient Case Management team, to ensure a high quality of patient care, reduced length of stay, efficient utilization of resources, and appropriate reimbursement of care and services, including discharge planning assistance and aftercare support. Time may be split between project work and performing clinical reviews. EDUCATION/ EXPERIENCE REQUIRED: Nursing Diploma or equivalent. Bachelor of Science of nursing degree preferred. Four (4) years hospital clinical experience medical, surgical, orthopedic, neuro-surgery or pediatric nursing. Demonstrated knowledge of pathophysiology with application of critical thinking skills. HMO or managed care experience preferred. Two (2) years Utilization Management and/or Hospital discharge planning in the acute care setting within the past four (4) years preferred. Knowledge of Medicare, Medicaid and NCQA guidelines and use of CMS website for research preferred. Home Health Care experience preferred. Excellent verbal and written communication skills, including telephone etiquette and telephone skills for review. Typing skills. Knowledge of use of Microsoft Office Suite. Knowledge of ICD-9/ ICD-10 and CPT coding, medical necessity criteria and medical terminology. Broad-based knowledge of the physiologic, psychosocial, environmental, family, economic and religious dynamics that can affect members. Excellent organizational skills, including use of time management principles to accomplish priorities effectively. Work professionally with physicians and all disciplines and levels of staff. Ability to interpret and follow HAP, Medicaid, Medicare and Medical Management policy and standards with specific time frames. Strong problem-solving, analytical and decision-making skills. Organization, planning skills and work with minimal supervision. Well-developed time management and prioritization required. Excellent customer servicing and positive interpersonal/relationship building. Supports diversity and inclusion. Display a positive attitude, take ownership and be accountable. CERTIFICATIONS/ LICENSURES REQUIRED: Current, valid Michigan license to practice as a Registered Nurse without any conditions, limitations or restrictions. Additional Information Organization: HAP (Health Alliance Plan) Department: Admissions & Concurrent Review Henry Ford Health Location: HAP (Health Alliance Plan) Shift: Day Job Union Code: Not Applicable