Utilization Review Specialist - Remote

If you're looking for a place to call home and grow, Three Crosses Regional Hospital is looking for you! We are looking for a Utilization Review Specialist – Remote that is committed to clinical excellence and building a patient-centered culture.

Three Crosses Regional Hospital is an advanced independent healthcare organization led by a local team of professionals dedicated to high quality patient care and being the first choice of patients and providers in the communities we serve.

We are dedicated to hiring team members that will adapt to our culture, pride themselves in professionalism, integrity, transparency, two-way communication, and ensuring the safety and well-being of our patients and staff.

Under the supervision of the Manager of Case Management, the Utilization Review Specialist performs Utilization Reviews and related programs as determined by appropriate committees on the Medical Staff or Administration in compliance with the appropriate regulatory agencies. Conducts review program functions, as delineated. May conduct preadmission planning functions.

The incumbent will carry-out duties by adhering to the highest standards of ethical and moral conduct, acts in the best interest of Three Crosses Regional Hospital, and fully supports the mission, vision, and values of Three Crosses Regional Hospital.

Responsibilities

• Responsible for reviewing assigned admissions, continued stays, utilization practices and discharge planning according to approved clinically valid criteria which meets the daily deadlines to obtain authorizations and complete other pertinent processes.
• Identify potential over/under utilization of services.
• Initiates appropriate referral to physician advisor in a timely manner.
• Understands proper utilization of health care resources and assists with identifying barriers to patient progress and collaborates with the interdisciplinary team.
• Conducts medical necessity review of all admissions. Utilizes approved clinical review criteria to determine medical necessity for admissions including appropriate patient status and continued stay reviews.
• Collaborates with the in-house staff and/or physician to clarify information, obtain needed documentation, present opportunities, and educate regarding appropriate level of care.
• Must understand the severity of an array of illnesses, intensity of service and care coordination needs.
• Facilitates the improvement of overall quality and completeness of medical record documentation.
• Must be able to integrate clinical knowledge with billing knowledge to review, evaluate and arrange peer to peer when clinical denials related to medical necessity of the patient while hospitalized.
• Actively promotes frequent communication between all team members, and providers.
• Coordinates, performs, and monitors all Utilization Review/management activities of the hospital to continuously improve the collection, reimbursement, coordination, and presentation of Utilization Review information; Educates hospital staff about requirements and trends.
• Communicates effectively with insurance companies, health maintenance organizations (HMOs) and other similar entities for approval of initial or additional inpatient days for treatment.
• Provides information they need in a logical, concise manner using technical language that accurately describes the patient’s condition and need for hospitalization.
• Prioritizes patient reviews based on situational analysis, functional assessment, medical record review, and application of clinical review criteria.
• Collaborates and maintains rapport and communication with the in-house care manager.
• Demonstrates the knowledge and skills necessary to provide care appropriate to the age of the patients served on his or her assignment.
• Works collaboratively with peers to achieve departmental goals in daily work as evidenced by appropriate and timely communication which is respectful and clear. Sensitive to workload of peers and shares responsibilities, fills in and offers to help.
• Actively participates in departmental process improvement team; planning, implementation, and evaluation of activities.
• Appeals all denials ensuring accuracy of information and effective coordination of correspondence.
• Initiates, coordinates, monitors and maintains documentation relevant to the appeals process.
• Provides information to physicians to assist them in their role in appeals.
• Attend staff meetings as needed.
• Other duties as assigned.

Education and Experience

• Required: Associate degree in nursing, Bachelor’s degree preferred
• Required: 2 years’ prior experience with Utilization Management
• Required: Ability to work on extremely complex problems where analysis of situation or data requires an evaluation of intangible variable factors.
• Required: Meet all Employee Health Requirement.
• Required: Current RN licensure
• Required: BLS certification

Three Crosses Regional Hospital is an equal opportunity employer.