Utilization Review Specialist | 40 hours per week | Utilization Review

Minimum Hiring Wage:
From $39.37 per hour

Job Details:
Scheduled Hours: Day shift, M-F

Job Description:

A Brief Overview

Responsible for the review of clinical documentation in the Electronic Medical Record (EMR), comparing it to the nationally accepted and evidence-based criteria to certify an admission to the facility, and for concurrent/continued stay review as appropriate. Also responsible for maintaining compliance with the CMS Conditions of Participation for Utilization Management.

What you will do

• Review inpatient encounters for medical necessity-Accurate and timely record review.-Gather and analyze clinical documentation to formulate an outcome.-Making decisions based on facts and evidence; assuming responsibility for those decisions.-Monitor cases for medical necessity/level of care.-Accurate input of data.-Manage multiple priorities.-Remains current with medical and surgical procedures, products and general trends in health care delivery.-Adhere to all state and Federal regulations for all UM reviews.-Practice utilization management activities within the scope of practice.
• Excellent Communication Skills-Effective and appropriate communication with physicians and insurance providers for the medical necessity of healthcare services.-Work incoming calls from patients, insurances, providers and facilities promptly.-Cooperate and work effectively with all department and staff to facilitate services to members and providers of care.-Maintain continuous, effective communication with other departments/disciplines.-Effective communication with patients and families regarding level of care and CMS guidelines
• Participates in continuous quality improvement activities.Facilitates appropriate cost effective and cost containment measures.
• Knowledge of electronic health record and software-Competent in Excel, Outlook and SharePoint-knowledge and ability to use web browser

Qualifications

• 4-6 years clinical experience Required
• Previous experience in Utilization Review Preferred
• Knowledge of the structure and content of the English language including the meaning and spelling of words, rules of composition, and grammar.
• Knowledge of the information and techniques needed to diagnose and treat human injuries, diseases, and deformities. This includes symptoms, treatment alternatives, drug properties and interactions, and preventive health-care measures.
• Knowledge of principles and processes for providing customer and personal services. This includes customer needs assessment, meeting quality standards for services, and evaluation of customer satisfaction.
• Knowledge of Utilization Management methods, principles and techniques.
• Knowledge of types of providers and services available for patients.
• Managing one's own time to ensure effective Utilization Management.
• Giving full attention to what other people are saying, taking time to understand the points being made, asking questions as appropriate, and not interrupting at inappropriate times.
• Being aware of others' reactions and understanding why they react as they do.
• Adjusting actions in relation to others' actions.
• Talking to others to convey information effectively.
• Using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions or approaches to problems.
• Understanding written sentences and paragraphs in work related documents.
• The ability to tell when something is wrong or is likely to go wrong. It does not involve solving the problem, only recognizing there is a problem.
• The ability to listen to and understand information and ideas presented through spoken words and sentences.
• The ability to combine pieces of information to form general rules or conclusions (includes finding a relationship among seemingly unrelated events).
• The ability to communicate information and ideas in speaking so others will understand.
• The ability to work cooperatively and effectively with other professionals in a team situation.
• The ability to collect and analyze information.
• The ability to make decisions relating to services provided to consumers.
• The ability to develop a logical and practical plan.
• The ability to evaluate the progress of patients.
• The ability to mediate with providers and other staff to resolve problems.
• The ability to arrange things or actions in a certain order or pattern according to a specific rule or set of rules (e.g., patterns of numbers, letters, words, pictures, mathematical operations).
• The ability to identify and understand the speech of another person.
• Registered Nurse Iowa Board of Nursing (IBON) (United States of America) Upon Hire Required

Qualifications:

• Associate degree in nursing (ADN) Required
• Bachelor's Degree in related field Preferred

Benefits:

We are excited to offer an aggressive compensation and benefits package for qualifying positions, which includes:

• Competitive base pay
• Matching retirement programs
• Health, Dental and Vision plans
• Health Savings and Flexible Spending Accounts
• Employee discounts including car rental, cell-phone plans
• Employer-paid, Long-Term Disability, Life, and AD&D
• Paid time off (PTO)
• Education Assistance Program
• Employee Assistance Program
• Employee Referral Bonus Program
• Discounted cafeteria meals
• Paid Parental Leave
• Employee Service Recognition program
• Voluntary plans including: Life, AD&D, Short-Term Disability, Critical Illness, Accident, Insurance, and Hospital Indemnity

Great River Health and its affiliates are Equal Opportunity employers. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity and expression, age, national origin, mental or physical disability, genetic information, veteran status, or any other status protected by federal, state, or local law.