Utilization Review Specialist

Position Summary:

Under the direct supervision of the HIM manager, the UR specialist monitors the utilization of resources, risk management and quality of care for patients in accordance to established guidelines and criteria for designated setting and status. Collection of clinical information necessary to initiate commercial payer authorization. Obtain and maintain appropriate documentation concerning services in accordance to reimbursement agency guidelines.

• Performs preadmission review on admissions when required by insurance companies/agencies to comply with policies and procedures.
• Works in coordination with discharge planner, monitoring medical necessity for admissions and appropriate level of services.
• May also need to notify physician and patient of authorization denials.
• Inputs collected data into computer system for insurance communication.
• Assists with retrospective review of specified charts as required.
• Obtains extensions in length of stays from insurance companies if needed.
• Obtains preauthorization and/or precertification of services.
• Reviews hospital records daily to determine if utilization resources could be served in a better environment, OBS vs INPT.
• Ability to interact on an interpersonal basis with providers and other staff within the organization.

• Education
  :
  Appropriate education level required in accordance with licensure.
• Experience
  :
  Three years of relevant experience with superior communication and interpersonal skills. Minimum one year healthcare or clinical experience required.
• License Requirements
  :
  Licensed Practical Nurse (LPN) license with State Nursing Board and/or possess multistate licensure privileges or a Registered Health Information Technician (RHIT) required. Additional coding certifications also acceptable such as certified coding specialist (CCS), certified coding specialist physician (CCS-P), certified professional coder (CPC) and certified professional coder – hospital (CPC-H).