Utilization Review Specialist

## Utilization Review Specialist Apply locations:
Bend, ORtime type:
Part time posted on:
Posted Todayjob requisition :
R1022420

Relief, Days  Pay range: $27.74 - $41.61
** ST. CHARLES HEALTH SYSTEM
**** JOB DESCRIPTION
***
* TITLE:

** Utilization Review Specialist
** REPORTS TO POSITION:
** Manager - Utilization Management
** DEPARTMENT:
** Utilization Management
** DATE LAST REVIEWED:
** August 2025
** OUR VISION:
** Creating America’s healthiest community, together
** OUR MISSION:
** In the spirit of love and compassion, better health, better care, better value
** OUR VALUES:
** Accountability, Caring and Teamwork
** DEPARTMENTAL

SUMMARY:

** The Utilization Management (UM) Department promotes and provides a centralized, collaborative multi-disciplinary approach to utilization management across St. Charles Health System. The UM Department supports physicians and clinical staff in identifying and improving care processes and systems for establishing and ensuring medical necessity, appropriate utilization of services, supporting denial avoidance and recovery and compliance with all local, state, and federal regulations.
*
* POSITION OVERVIEW:

** The
** Utilization Review Specialist
** works under the direction of the Utilization Management Manager and acts as an interdisciplinary team member within the Utilization Management Department.

The Utilization Review Specialist is responsible for providing verification of benefits, authorization procurement and other assigned tasks. In addition, the Utilization Review Specialist is responsible for collaborating with the UM RN and other members of the interdisciplinary team (i.e. Physicians, Case Managers, Social Workers, etc.) or interdependent departments (i.e. Patient Access, Billing, etc.) to avoid unnecessary delays in patient care, discharge, or billing.

The Utilization Review Specialist will serve as the first point of escalation for payors requiring assistance in gaining additional or missing information to support authorization. The Utilization Review Specialist is responsible for ensuring procurement of authorization upon admission, discharge, and accuracy of authorization information. In addition, the Utilization Review Specialist ensures timely escalation of barriers to authorization requiring clinical expertise and assist in coordination of Peer to Peer discussions with the payor.

This position does not directly supervise any other caregivers.
** ESSENTIAL FUNCTIONS AND DUTIES:
** Acts as interdisciplinary team member within the Utilization Management (UM) department.

Accurately completes assigned (triaged by UMS) requests submitted from payors; promptly escalates cases requiring clinical expertise to UM RN and / or multidisciplinary team.

Escalates Medical Necessity (patient status / LOC) concerns and other UM concerns to the Physician Advisor.

Submits clinical reviews to payors. Submits clinical information supporting admission, continued stay reviews, and provides discharge information to payors upon request.

Identifies and escalates all 1MN Medicare and 2MN Obs stays for review at committee through use of assigned work queues.

Reviews and addresses all discharged encounters pending payor authorization follow-up (i.e. additional authorized days, authorization accuracy).Maintains a working knowledge of UM specific changes (i.e. changes in authorizations, payor contracts, CMS, and regulatory requirements).Prepares and facilitates the delivery of regulatory notices and ensures compliance with payor regulations.

Supports clinical denials and appeals processes, both concurrent and post claim.

Supports peer to peer workflows and the discharge appeal process.

Collaborates with the Case Management and Social Work teams (i.e. extended observation stays, patients no longer meeting medical necessity, status changes).Communicates and collaborates with Patient Access, Patient Financial Services (PFS) and Health Information Management (HIM).Provides timely and continual coverage of assigned work area to ensure all accounts are complete.

Documents all interactions with patient, family / caregiver, and patient’s care team.

Complies with all documentation requirements.

Follows up on action items prior to the end of shift and completes all tasks within department guidelines.

Adheres to the policies, procedures, rules, regulations, and laws of the hospital and federal and state governing bodies.

Assists Department Manager with quality audits.

Participates in tracking of departmental quality measures by abstracting and reporting UM data.

Supports the vision, mission and values of the organization in all respects.

Supports Value Improvement Practice (VIP
- Lean) principles of continuous improvement with energy and enthusiasm, functioning as a champion of change.

Provides and maintains a safe environment for caregivers, patients and guests.

Conducts all activities with the highest standards of professionalism and confidentiality.  Complies with all applicable laws, regulations, policies and procedures, supporting the…