Utilization Review Specialist

• SIGN-ON BONUS: $5,000 - if Licensed Registered Nurse (RN)

ESSENTIAL FUNCTIONS:

• Act as liaison between managed care organizations and the facility professional clinical staff.
• Conduct reviews, in accordance with certification requirements, of insurance plans or other managed care organizations (MCOs) and coordinate the flow of communication concerning reimbursement requirements.
• Monitor patient length of stay and extensions and inform clinical and medical staff on issues that may impact length of stay.
• Gather and develop statistical and narrative information to report on utilization, non-certified days (including identified causes and appeal information), discharges and quality of services, as required by the facility leadership or corporate office.
• Conduct quality reviews for medical necessity and services provided.
• Facilitate peer review calls between facility and external organizations.
• Initiate and complete the formal appeal process for denied admissions or continued stay.
• Assist the admissions department with pre-certifications of care.
• Provide ongoing support and training for staff on documentation or charting requirements, continued stay criteria and medical necessity updates.

OTHER FUNCTIONS:

• Perform other functions and tasks as assigned.

EDUCATION/EXPERIENCE/SKILL REQUIREMENTS:

• Associate's degree in nursing (LPN or RN) required. Bachelor's or Master’s degree in social work, behavioral or mental health, nursing or other related health field preferred.
• Two or more years' experience with the population of the facility and previous experience in utilization management preferred.

LICENSES/DESIGNATIONS/CERTIFICATIONS:

• Current licensure as an LPN or RN within the state where the facility provides services; or current clinical professional license or certification, as required, within the state where the facility provides services.
• CPR and de-escalation and restraint certification required (training available upon hire and offered by facility.
• First aid may be required based on state or facility requirements.

ADDITIONAL REGULATORY REQUIREMENTS:

While this job description is intended to be an accurate reflection of the requirements of the job, management reserves the right to add or remove duties from particular jobs when circumstances
(e.g. emergencies, changes in workload, rush jobs or technological developments) dictate.

Education

• Associates or better in Nursing/Healthcare

• Masters or better in Nursing/Healthcare or related field
• Bachelors or better in Nursing/Healthcare or related field

Licenses & Certifications

• Reg Nurse

Skills

• Problem Solving
• Communication
• Attention to Detail

Behaviors

• Dedicated: Devoted to a task or purpose with loyalty or integrity
• Team Player: Works well as a member of a group
• Detail Oriented: Capable of carrying out a given task with all details necessary to get the task done well

Motivations

• Self-Starter: Inspired to perform without outside help
• Goal Completion: Inspired to perform well by the completion of tasks
• Flexibility: Inspired to perform well when granted the ability to set your own schedule and goals