Quality Utilization Specialist Full-time, Days, Hybrid ($4,000 sign-on bonus)
Job Description
The Quality Utilization Specialist reflects the mission, vision, and values of NM, adheres to the organization’s Code of Ethics and Corporate Compliance Program, and complies with all relevant policies, procedures, guidelines and all other regulatory and accreditation standards.
Responsibilities
Applies medical necessity screening criteria, level of care guidelines, and professional nursing knowledge to ensure that admissions & length of stay are appropriate
Completes initial admission and thereafter continuing stay reviews for all hospitalized patients
Facilitates utilization review concurrent with decisions on hospitalization and may perform duties in the Emergency Department, pre and post-operative, labor and delivery, external transfer, bed assignment, and / or other access points for hospitalization
Collaborates with the Payor Specialists and third-party payors to effectively communicate all relevant clinical information based on clinical indicators and the plan of care
Acts as a liaison with the clinical care team assuring compliance with managed care contracts and payor guidelines while maintaining quality of care
Partners with operational and medical leadership to identify, develop and implement utilization processes that foster the right care at the right time in the right setting
Makes appropriate referrals to internal physician advisors and contracted third party review company per Department guidelines
May assist in the reporting of financial indicators including length of stay, resource utilization, denials and appeals
Participates in the development, implementation, evaluation and revision of quality utilization tools in collaboration with the healthcare team
Affords assistance in Recovery Audit Contractor (RAC) and other audit follow up and appeals on insurance denials as requested
Qualifications
Licensed Registered Nurse in the state of Illinois (IDFPR)
Bachelor’s Degree in Nursing
5 years of experience in acute inpatient hospital care
Proven leadership and diplomacy skills to affect positive outcomes
Organizational, team building, coaching, and conflict management to maximize the achievement of utilization outcomes
Analytical skills necessary to independently collect, analyze, and interpret data, resolve problems requiring innovative solutions
Computer skills including word processing and spreadsheets