Utilization Review (12189)

Job Summary:    

• Collaborate closely with physicians, nurses, and other members of the care team to gather necessary clinical information and provide guidance on documentation.
• Support physician provision of patient care with accountability for designated patient case load.   
• Facilitate precertification and payor authorization processes and facilitate collaborative management of patient care across the continuum, intervening as necessary.    
• Conduct timely and thorough concurrent reviews of inpatient admissions to determine medical necessity and appropriateness of the level of care, using evidence-based criteria.
• Serve as a primary liaison between the hospital and third-party payers, submitting clinical reviews and securing authorizations for continued stays.
• Identify and escalate cases that do not meet criteria to the Physician Advisor for a secondary review and determination.
• Actively participate in daily multidisciplinary rounds to discuss patient progress, care plans, and barriers to discharge.
• Ensure that all review activities are documented accurately and comprehensively within the electronic health record (EHR) and case management systems.
• Assist in the collection and analysis of utilization data to identify trends and opportunities for process improvement within the hospital.
• Demonstrate and encourage team behavior and exceptional patient/guest experiences.      
• Uphold and promote patient safety and quality.     

Education:                

• Must hold a current, unrestricted Registered Nurse (RN) license in the state.
• A Bachelor of Science in Nursing (BSN) is strongly preferred.

Experience:                

• A minimum of three years of recent clinical experience in an acute care setting, such as Med-Surg, ICU, or ER, is required.
• At least two years of direct experience in hospital-based utilization review or case management is highly desirable.
• Demonstrated proficiency with clinical criteria sets like InterQual or MCG.

Additional Skills/Abilities:                

• Conduct concurrent and retrospective reviews of patient medical records to verify the medical necessity of services provided.
• Assess admission criteria and length of stay, applying standardized clinical guidelines such as InterQual or MCG to justify care levels.
• Collaborate with physicians and other healthcare providers to discuss patient care plans and ensure alignment with coverage policies.
• Facilitate communication between medical staff and payers to resolve issues related to treatment plans and reimbursement.
• We are looking for a professional who is passionate about quality care and efficient healthcare delivery. The ideal candidate will possess sharp critical thinking skills and the ability to thrive in a dynamic, team-oriented environment.
• Excellent communication and interpersonal skills, with an ability to engage effectively with physicians and payers.
• Strong organizational skills and the ability to manage multiple cases simultaneously in a fast-paced setting.
• Must be proficient in Microsoft Word and Excel. Excellent organizational skills are required. Must be able to set priorities appropriately and handle multiple issues concurrently.