Position Summary

The Utilization Review Specialist monitors adherence to the hospital's utilization review plan to ensure the effective and efficient use of hospital services and monitors the appropriateness of hospital admissions and extended hospital stays. The evaluation of the appropriateness and medical necessity of health care services, procedures, and facilities is conducted through the application of evidence-based criteria or guidelines, and through authorization/prior authorization under the provisions of an applicable health insurance plan.

Primary Position Responsibilities

1. Performs utilization activities, using Milliman Care Guidelines under the guidance of the Physician Advisor, to provide clinical information to payors as requested and ensures correct status of all patients to insure maximum reimbursement.

2. Works with medical and clinical staff to improve overall quality and completeness of clinical documentation.

3. Communicates and educates medical, clinical and coding staff of trends and opportunities for improvement.

4. Tracks and trends all queries presented to medical and clinical staff.

Qualifications

Minimum Education:

Required:

All hires after July 2012 are required to have a Bachelor's Degree in nursing OR if Associates Degree or Diploma, RN must provide proof of enrollment in a BSN program prior to hire, be continuously enrolled and complete within 5 years of hire date or internal RN promotion date.

Minimum Years of Experience (Amount, Type and Variation):

Required:

Three years of medical/surgical hospital based direct patient care experience.

Preferred:

Five years of medical/surgical hospital based direct patient care experience.

License, Registry or Certification:

Required:

Current NJ RN Licensure. 

Knowledge, Skills and/or Abilities:

Required:

Excellent verbal, written, organizational and interpersonal skills. Demonstrates experience in patient care evaluation methodologies, analysis and reporting of patient clinical data to various payee sources using Miliman Care Guideline criteria sets.