RN - Utilization Review Specialist PRN - SSO Utilization Review - USA Health Shared Services

Overview

USA Health is Transforming Medicine along the Gulf Coast to care for the unique needs of our community. USA Health is changing how medical care, education, and research impact the health of people who live in Mobile and the surrounding area. Our team of doctors, advanced care providers, nurses, therapists, and researchers provides the region's most advanced medicine at multiple facilities, campuses, clinics, and classrooms. We offer patients convenient access to innovative treatments and advancements that improve the health and overall well-being of our community.

Responsibilities

Responsibilities Performs functions independently, according to policy and third party payor requirements, to include: quality reviews, prior authorizations, initial/admission reviews, continued stay reviews, discharge reviews, retrospective reviews, appeals as appropriate for denials, and case management reviews for DRG payors

Analyzes medical record data to complete functions

Collaborates with members of the healthcare team, patients, families, and managed care workers to formulate appropriate discharge plans and promote a safe and timely flow through inpatient setting

Ensures optimal reimbursement from third party payors through appropriate implementation of Utilization Review functions

Communicates with healthcare providers via telephone, in person, and email (i.e., discussion with physicians regarding plan of care, length of stay, and stay type)

Establishes and maintains a professional relationship with third party payor representatives

Participates in interdisciplinary patient care meetings as assigned

Utilizes a PC to access the Hospital Information System

Enhances professional growth and development through participation in educational programs

Completes annual education on nationally recognized level of care criteria

Participates in all Utilization Review audit activities as assigned

Orients new staff to the Utilization Review process as assigned

Reports quality of care concerns discovered during Utilization Review functions to the Director

Evaluates chart documentation for completeness relative to current ICD requirements and communicates deficiencies

Demonstrates proficiency in Early Periodic Screening Diagnosis and Treatment (EPSDT) by performing independently, according to regulatory requirements, the following functions as assigned

Identification of patient eligibility, collection of data required to perform screening, performance of Inter-periodic Screening Components, and communication of screening findings to all related parties

Maintains accurate and complete records both written and via personal computer

Documents reviews according to hospital policy

Completes/documents forms/requests from third party payors and regulatory parties

Documents variances, discharge plans and EPSDT functions

Utilizes proper body mechanics when moving equipment that is necessary to perform essential functions

Communicates and uses appropriate customer relation skills with physicians, patients, families and healthcare team in person and via telephone

Responds to overhead pages

Accesses and accurately maintains electronic and paper medical records

Participates on committees as assigned

Participates in Performance Improvement activities as assigned

Completes all mandatory department, educational and hospital requirements

Adheres to current Infection Control and Safety Standards

Regular and prompt attendance

Ability to work schedule as defined and overtime as required

Related duties as assigned

Additional Information

Employees must be in a regular position, working 20 hours or more per week (.50 FTE or greater) to qualify for benefits.

Qualifications

Graduation from an accredited school of nursing meeting the minimum standards set by the State of Alabama and 2 years or professional nursing experience Required

Bachelor's Degree or Master's Degree in nursing Preferred

Utilization Review experience Preferred

RN - Registered Nurse - State Licensure and/or Compact State Licensure Required

Comparable combination of education and experience may substitute for the above requirements.