Concurrent Denial Nurse BU

CCIR CBA Bidding Date 01/07/2026 - 01/14/2026Join the Cleveland Clinic team where you will work alongside passionate caregivers and provide patient-first healthcare. You will work alongside dedicated caregivers, receive endless support and appreciation, and build a rewarding career with one of the most respected healthcare organizations in the world.As a Concurrent Denial Nurse,you will support the Utilization Management Departmentbyreviewing concurrent and retrospective clinical inpatient denials to ensure medical necessity criteriaismet.We are looking for aRegisteredNurse who is a subject matter expert inutilizationmanagement,has experience with MCG criteria,andiscomfortable educating Caregivers and this role, you will get to work with a dynamic team of like-minded professionalsand gain experience at an elite healthcare organization.A caregiver in this position worksdays from7:30AM - 4:00PM, including rotating Saturdays.A caregiver who excels in this role will:Serve as the expert in Utilization Management functions andbea resource to the department in general and the hospital.Review and analyze concurrent and retrospective clinical denials and follow the specific payer processes.Serve as an expert in payer specific process and communicate between payer and CCIRH to identify/resolve denial process issues.Work in collaboration with the local physician advisor team and support thepeer-to-peerprocess.Perform the routine activities of a UM Specialist when needed while taking a leadership role.Utilize knowledge of medical terminology, anatomy and physiology, diagnosis, surgicalproceduresand basic disease processes.Utilize knowledge and experience with Care Guidelines and /or other UM criteria sets.Utilize advanced interpersonal and communication written and verbal skills necessary to gather and exchange data (both internally and externally) with members of the health care team.Recommend resourceutilizationwhen needed.Utilize analytical skills to gather data,identifyproblemsandfacilitateresolution.Prioritize and organize work to meet changing priorities.Utilize knowledge of multiple hospital information systems anddepartment’ssoftware.Assistwith education and monitoring of UMspecialist'sreviews.Participate in payer specific p2p calls or local meetings as needed.Minimum qualifications for the ideal future caregiver include:Completion of an accredited Registered Nursing Program (RN)Bachelor’sDegree in Nursingor related fieldCurrent valid license in the State of Florida as a Registered Nurse (RN)Basic Life Support (BLS) certificationthrough the American Heart Association (AHA) or American Red CrossThree years of full-time Utilization Management experienceDemonstrated above average competence in Utilization Management ProcessesPreferred qualifications for the ideal future caregiver include:Case Management certification (CCM or ACM)Physical Requirements:Requires extensive reading, telephone , computer useMust be able to work well under pressure and maintain professional demeanor under adverse conditionsPersonal Protective Equipment:Follows Standard Precautions using personal protective equipment as requiredPay RangeSalaries [which may be] shown on independent job search websites reflect various market averages and do not represent information obtained directly from The Cleveland Clinic. Because we value each individual candidate, we invite and encourage each candidate to discuss salary/hourly specifics during the application and hiring process.

Created: 2026-01-16