Specialist , Utilization Review Casual - Requisition #840534

Job Summary

Reviews and screens the appropriateness of services, the utilization of hospital resources and the quality of patient care rendered.

• Consistently uses an outward mindset and puts forth exemplary effort in accomplishing his/her goals and objectives in a manner that helps others to achieve their goals and objectives.
• Conducts concurrent or extended stay reviews on appropriate day and/or specified time
• Combines clinical, business and regulatory knowledge and skill to reduce significant financial risk and exposure caused by concurrent and retrospective denial of payments for services provided
• Prepares and submits appeals to payors, effectively coordinating collection of all pertinent data to support the hospital and patient’s position
• Maintains and updates reviews in the electronic medical record (EMR) and maintains other appropriate records as needed
• Communicates pertinent payor issues to physician and other caregivers
• Understands and communicates insurance information to team members, including benefits and levels of care
• Prepares any reports assigned or requested by the Manager of Case Management or his/her supervisor

Licensed in the State of Michigan as a Registered Nurse. Three (3) years of clinical experience.

Bachelor’s degree preferred. Previous utilization management or case management experience preferred. Demonstrated competence with basic Microsoft Office tools. Knowledge of outside regulatory agencies inter‑face with the institution. The ability to communicate with individuals from various backgrounds regarding a variety of hospital‑wide practices. Strong critical thinking skills necessary to assess documentation of care provided in EMR. Excellent prioritization and organizational skills emphasized.

Work is generally sedentary in nature, but may require standing and walking for up to 10% of the time. Work is generally performed within an office environment, with standard office equipment available.

Marshall, 200 N. Madison, Marshall, MI 49068