Utilization Review Specialist; Tr​/Prn

Utilization Review Specialist

Riverside Healthcare is seeking a skilled and detail-oriented Utilization Review Specialist to join our team in Kankakee, Illinois. This role is pivotal in evaluating the appropriateness of patient care services and ensuring that the care provided aligns with clinical guidelines and payer requirements. The Utilization Review Specialist will work closely with healthcare providers, insurance companies, and patients to ensure optimal resource utilization and effective care management.

Essential Duties

Review and Assessment:

• Conduct comprehensive reviews of patient cases to assess the necessity, appropriateness, and efficiency of care.
• Analyze clinical documentation and determine the medical necessity of admissions, continued stays, and various treatments.

Collaboration and Communication:

• Liaise with physicians, nurses, and other healthcare professionals to gather relevant information and discuss patient care plans.
• Interact with insurance companies to secure authorizations for services and ensure compliance with payer policies.
• Collaborates with Patient Financial Services in the denials/appeals process as part of revenue cycle

Documentation and Reporting:

• Maintain accurate records of all utilization review activities, including assessments, communications, and decisions.
• Prepare detailed reports and summaries for internal use and for submission to insurance providers as required.

Compliance and Policy Adherence:

• Ensure that all reviews and recommendations comply with hospital policies, regulatory requirements, and payer guidelines.
• Stay updated on changes in healthcare regulations and payer requirements to maintain compliance.

Quality Improvement:

• Participate in quality improvement initiatives aimed at enhancing the efficiency and effectiveness of patient care services.
• Analyze trends and patterns in utilization data to identify opportunities for process improvements and cost savings

These are duties that MUST be performed in this job, with or without reasonable accommodation.

Non-essential Duties

Assist in the training and orientation of new staff members on utilization review processes and protocols.

Support administrative tasks related to utilization review and case management as needed.

Contribute to departmental meetings and provide input on policy updates and process enhancements.

Required Experience

• Minimum of 2 years of experience in a clinical setting, with a strong preference for experience in utilization review, case management, or a related field.

Preferred Experience

• In-depth understanding of clinical guidelines, payer requirements, and healthcare regulations
• Strong analytical and critical thinking skills to assess complex cases and make informed decisions.
• Excellent written and verbal communication skills for effective interaction with healthcare providers, patients, and insurance companies.
• Proficiency in electronic health record (EHR) systems and utilization review software.
• Knowledge of Inter Qual and/or MCG
• Knowledge of local and national coverage determinations

Required Licensure/Education

• Associates Degree in Nursing (ADN), Healthcare Administration, or a related field from an accredited institution.
• Active Registered Nurse (RN) license or relevant professional certification in the State of Illinois is highly desirable.

Preferred Education

• Certification in Utilization Review or Case Management (e.g., Certified Professional in Utilization Review (CPUR) or Certified Case Manager (CCM)) is preferred.
• Bachelors Degree in Nursing (BSN) or higher

Employee Health Requirements

Exposure/Sensory Requirements:

Exposure to:

Chemicals: N/A

Video Display Terminals:
Average

Blood and Body Fluids:
None

TB or Airborne Pathogens:
None.

Sensory requirements (speech, vision, smell, hearing, touch):

Speech:
Training/presentations, telephone communication, facilitating meetings.

Vision:
Read computer screens and printouts, memos, communications, documentation, and literature.

Smell:
Sensitivity and recognition of odors derived from various cleaning processes, odors generated from malfunctioning equipment.

Hearing:
Telephone communications, meetings, and equipment operating characteristics.

Touch:
Writing and…