Utilization Review Specialist

Description

PURPOSE STATEMENT:

Proactively monitor utilization of services for patients to optimize reimbursement for the facility.

ESSENTIAL FUNCTIONS:

Act as liaison between managed care organizations and the facility professional clinical staff.

Conduct reviews, in accordance with certification requirements, of insurance plans or other managed care organizations (MCOs) and coordinate the flow of communication concerning reimbursement requirements.

Monitor patient length of stay and extensions and inform clinical and medical staff on issues that may impact length of stay.

Gather and develop statistical and narrative information to report on utilization, non-certified days (including identified causes and appeal information), discharges and quality of services, as required by the facility leadership or corporate office.

Conduct quality reviews for medical necessity and services provided.

Facilitate peer review calls between facility and external organizations.

Initiate and complete the formal appeal process for denied admissions or continued stay.

Assist the admissions department with pre-certifications of care.

Provide ongoing support and training for staff on documentation or charting requirements, continued stay criteria and medical necessity updates.

OTHER FUNCTIONS:

Perform other functions and tasks as assigned.

EDUCATION/EXPERIENCE/SKILL REQUIREMENTS:

Associates degree in nursing (LPN or RN) required. Bachelors or Master’s degree in social work, behavioral or mental health, nursing or other related health field preferred.

Two or more years experience with the population of the facility and previous experience in utilization management preferred.

LICENSES/DESIGNATIONS/CERTIFICATIONS:

Current licensure as an LPN or RN within the state where the facility provides services; or current clinical professional license or certification, as required, within the state where the facility provides services.

CPR and de-escalation and restraint certification required (training available upon hire and offered by facility.

First aid may be required based on state or facility requirements.

SHIFT:

Monday – Friday from 8 a.m. to 5:00 p.m.

PAY RANGES:

LPN: $27.19 to $35.17/hr

RN: $38.18 to $49.38/hr

Qualifications

Skills

Required

Problem Solving: Intermediate

Communication: Intermediate

Attention to Detail: Intermediate

Behaviors

Required

Dedicated: Devoted to a task or purpose with loyalty or integrity

Team Player: Works well as a member of a group

Detail Oriented: Capable of carrying out a given task with all details necessary to get the task done well

Motivations

Required

Self-Starter: Inspired to perform without outside help

Goal Completion: Inspired to perform well by the completion of tasks

Flexibility: Inspired to perform well when granted the ability to set your own schedule and goals

Education

Required

Associates or better in Nursing/Healthcare

Preferred

Masters or better in Nursing/Healthcare

Bachelors or better in Nursing/Healthcare

Licenses & Certifications

Required

Reg Nurse

Experience

Preferred

2 years: Two or more years experience with the population of the facility and previous experience in utilization management preferred.