The Utilization Review Specialist assumes responsibility and accountability for admission and concurrent reviews assuring the prevention of denials from all payers, as well as appeals of all accounts reviewed and deemed appropriate for appeal. The Specialist will create a structure for resolution of root cause denial trends by continuously working to identify opportunities for workflow improvements.

Responsibilities include analyzing patient records to determine legitimacy of admission, treatment, and length of stay in health-care facility to comply with government and insurance company reimbursement policies; analyzing insurance, governmental, and accrediting agency standards to determine criteria concerning admissions, treatment, and length of stay of patients.

EXPERIENCE / SKILLS:

• Licensed Registered Nurse within the state of residence; experience in case management/utilization review w/in an acute care organization.
• Significant experience in the healthcare field is required including a minimum of five years as a clinical nurse in an acute care setting. In addition, having at least five to seven years of experience in case management, discharge planning, and/or utilization review is preferred.
• Knowledge of regulatory and payer requirements for Case Management Activities..
• Ability to critically evaluate and make decisions about whether discharge planning for highly difficult cases
• Ability to use pre-existing criteria sets and/or clinical evidence from an existing library of clinical references and/or regulatory arguments to support one’s own clinical appeals arguments
• Maintains confidentiality of patient data and medical records in compliance with HIPAA regulations.
• Ability to read, evaluate, and abstract important information from handwritten patient medical records.
• Excellent oral and technical writing and typing skills.
• Demonstrates flexibility with a willingness to learn and adapt to changes in regulations and task-related priorities.
• Ability to successfully work independently and to adapt quickly to changing priorities and regulations. Excellent oral and technical writing skills and the Ability to maintain confidentiality according to HIPAA regulations is required.