Utilization Review Specialist; RN

Job Summary

Scheduled Weekly

Hours:

40. The Utilization Review (UR) Specialist has well-developed knowledge and skills in utilization management, medical necessity, and patient status determination. This individual supports the UM program by developing and/or maintaining processes for determining the appropriate admission status based on the regulatory and reimbursement requirements of various commercial and government payers. The UR Specialist performs a variety of concurrent and retrospective UM-related reviews, ensures that appropriate data is tracked, evaluated, and reported, and helps monitor the effectiveness/outcomes of the UM program, identifying and applying appropriate metrics, evaluating the data, reporting results to various audiences, and designing and implementing process improvement projects as needed.

The UR Specialist helps to identify, develop, and provide orientation, training, and competency development for all appropriate staff and colleagues on an ongoing basis and actively participates in process improvement initiatives, working with a variety of departments and multi‑disciplinary staff. The UR Specialist maintains current knowledge of commercial and government payers and regulations, guidelines, and criteria related to UM, and ensures that the UM program maintains documented, up‑to‑date policies and procedures and that all UM key processes have valid outcome measures that are monitored for compliance and reported to appropriate stakeholders.

The UR Specialist effectively and efficiently manages a diverse workload in a fast‑paced, rapidly‑changing regulatory environment and is a member of and provides support to the hospital’s UR Committee. He/she collaborates with multiple colleagues at various levels throughout Sturdy for the purpose of supporting and improving the UM program.

• Perform correct identification of patient status (inpatient, observation status) so that appropriate claims can be submitted to commercial and government payers.
• Complete short stay reviews (one midnight) and track and trend results for reporting and education purposes.
• Identify opportunities for process and system improvement and initiate and support performance improvement as indicated.
• Collaborate with nursing, physicians, admissions, fiscal, legal, compliance, coding, and billing staff to answer clinical questions related to medical necessity and patient status.
• Facilitate annual update of Inter Qual software, assist in creation of training tools, and provide training as needed to RN CMs.
• Develop review process for OR and ED patients at portals of entry.
• Maintain knowledge of all insurance plan regulations including CMS/Medicaid to ensure compliance with all required processes and documentation, while minimizing denials.
• Use critical thinking and problem‑solving skills to facilitate safe and timely patient transitions of care.
• Interpret patient‑related information, evaluate appropriateness of continued stay and/or need for ancillary services, and re‑assess discharge planning needs based on daily assessment.
• Utilize industry‑accepted utilization and/or medical management criteria in patient status decision making.

• Minimum 3–5 years acute‑care case management experience with demonstrated skills in utilization review.
• Excellent computer skills; adept at utilizing Excel and other software programs to prepare and present data and trend charts at Utilization Review Committee meetings.
• Strong analytical ability to interpret patient‑related information and evaluate appropriateness of continued stay or need for ancillary services.
• Knowledge in areas of Medicare and Medicaid UM regulations, Inter Qual, Medicare Inpatient Only List, RAC, QIO, MAC, and Denial Management.
• Strong aptitude in data analytics to aggregate and monitor utilization data, reporting out on trends and key metrics.
• Self‑starter able to function independently within the scope of the position and licensure, as well as department policies and established goals.
• Excellent communication skills and positive interpersonal dynamic in working with a variety of stakeholders across the care continuum,…