Utilization Review Specialist (RN)

Scheduled Weekly Hours

Scheduled Weekly Hours: 40

About the Role

The Utilization Review (UR) Specialist has well-developed knowledge and skills in areas of utilization management (UM), medical necessity, and patient status determination. This individual supports the UM program by developing and/or maintaining effective and efficient processes for determining the appropriate admission status based on the regulatory and reimbursement requirements of various commercial and government payers. This individual is responsible for performing a variety of concurrent and retrospective UM-related reviews and functions and for ensuring that appropriate data is tracked, evaluated, and reported. This individual helps monitor the effectiveness/outcomes of the UM program, identifying and applying appropriate metrics, evaluating the data, reporting results to various audiences, and designing and implementing process improvement projects as needed. This individual helps to identify, develop, and provide orientation, training, and competency development for all appropriate staff and colleagues on an ongoing basis and actively participates in process improvement initiatives, working with a variety of departments and multi-disciplinary staff.

Responsibilities

• Facilitate correct identification of patient status (inpatient, observation status) so that appropriate claim can be submitted to commercial and government payers
• Complete short stay reviews (one midnight); track and trend results for reporting and education purposes
• Identify opportunities for process and system improvement and initiate and support performance improvement as indicated
• Collaborate with nursing, physicians, admissions, fiscal, legal, compliance, coding, and billing staff to answer clinical questions related to medical necessity and patient status
• Facilitate annual update of InterQual software (collaborating with Information Systems staff), assist in creation of training tools, and provide training as needed to RN CMs
• Develop review process for OR and ED patients at portals of entry

Requirements

• Minimum 3-5 years acute care case management experience, with demonstrated skills in utilization review
• Excellent computer skills: Adept at utilizing Excel and other software programs to prepare and present data and trend charts at Utilization Review Committee Meetings
• Demonstrated ability to use critical thinking and problem solving skills in facilitating safe and timely patient transitions of care
• Excellent communication skills and positive interpersonal dynamic in working with a variety of stakeholders across the care continuum, including physicians
• Strong analytical ability to interpret patient-related information, evaluate appropriateness of continued stay and/or need for ancillary services, and to reassess discharge planning needs based on daily assessment
• Ability to successfully utilize industry accepted utilization and or medical management criteria in patient status decision making
• Self-starter able to function independently within the scope of position and licensure, as well as department policies and established goals

Qualifications

• Bachelor of Science in Nursing (BSN) Graduate of an accredited school of nursing with advanced degree preferred
• RN with current Massachusetts license required
• CCM (Certified Case Manager) and/or ACMA (Accredited Case Manager)
• Board Certification in Nursing Case Management (RN-BC) through ANCC (American Nurses Credentialing Center)

Skills

• Knowledge in areas of: Medicare and Medicaid UM regulations, InterQual, Medicare Inpatient Only List, RAC, QIO, MAC, and Denial Management

Benefits

Salary Range: $93,725.54-$146,082.56 Salary Range Details The pay range displayed on each job posting reflects the anticipated range for new hires. A successful candidate’s actual compensation will be determined after taking factors into consideration such as the candidate’s work history, experience, skill set, and education. This is not inclusive of the value Sturdy Health’s benefits package (if applicable), which includes among other benefits, healthcare/dental/vision and retirement. For annual salaries this is based on full-time employment.

Pay

Salary Range: $93,725.54-$146,082.56

Schedule

Full-Time