Commercial Review Specialist I

About the role

The UR-CR Specialist I ensures patient care services are appropriately recorded and utilized in accordance with hospital quality standards, regulatory agency policies, and reimbursement entity contracts. This involves thorough chart reviews and first-level screening to confirm patients receive the appropriate level of care throughout their hospital stay.

The role collaborates with the medical team and UR medical directors to establish the correct level of care and acts as a liaison for discharge appeals and social admissions, preparing regulatory notices for patients.

Responsibilities

• Conduct thorough chart reviews using first-level screening criteria to ensure appropriate patient level of care.
• Collaborate with medical teams and UR medical directors to determine and establish the appropriate level of care.
• Act as a liaison for discharge appeals and social admissions.
• Prepare and deliver regulatory notices to patients.
• Interface and collaborate with leadership, colleagues, providers, Physician Advisors, regulatory agencies, and other healthcare-related entities.
• Manage assignments and responsibilities in a hybrid work setting, seeking additional support or guidance when necessary.

Requirements

• NYS Licensed/Registered (or eligible) RN.
• Bachelor’s Degree in Nursing and a minimum of three years post-RN licensure acute care nursing experience, or Associate’s Degree in Nursing and five years post-RN licensure acute care nursing experience.
• Comprehensive and broad knowledge of complex clinical and medical concepts.
• Proficiency in clinical conceptual understanding for level of care review.
• Strong written, verbal, and interpersonal communication skills.
• Strong organizational skills.
• Proficiency in technology use, including PC, Windows, Microsoft applications, Zoom/WebEx platforms, etc.

Preferred Qualifications

• Utilization management or utilization review experience.
• Experience with level of care screening criteria and CMS regulations related to hospital admissions.
• Experience interfacing with healthcare payers or regulatory agencies.

Schedule

• Monday through Friday, 8:00 AM – 4:30 PM, with rotating weekends.