Utilization Review Clinical Specialist Jobs

Experience - 3 years in general or specialty nursing practice

Education - Diploma, Associate's Degree or Bachelor's Degree from accredited RN program

License - Current and unrestricted Louisiana RN license

Coordinates appropriate bed placement in conjunction with Patient Care Services and the Bed Coordinator.

Performs other duties as assigned or requested.

Knowledge of UR processes required for all payor sources i.e. precertification, concurrent reviews, discharge review.

Complete initial precertification for all levels of care.

Collaborate with clinicians/case managers to obtain pertinent clinical and discharge information.

Liaison between insurance and clinical staff, providing information to clinicians/case managers regarding dispositions that would be approved by insurance.

Consult with Admissions Department regarding specific LOC issues, insurance requests, and/or criteria questions.

Conduct concurrent reviews on assigned cases.

Experience with PHP/IOP and SUD.

Experience working with commercial health plans.

Experience w admission and concurrent reviews.

Perform all other duties as assigned Skills:

5 years of Utilization Review.

Ability to create a sense of urgency.

Maintains knowledge of Payer requirements for peer to peer process, Skilled nursing facility authorization, & LTAC reviews.

Provides provider and care team ongoing education regarding utilization review/management.

Verifies authorization of services and communicates information to case management/nursing team.

Makes decisions based on evidence based practice, research, and UR nurse higher order critical thinking skills and experience.

Maintains knowledge of Payer requirements regarding length of stay for observation and transition to Inpatient

Documents actions taken and outcome(s) in Cerner Case Management tool, payer information.

Yes, Home Health Care Experience is required and OASIS certification is preferred. Additional+2 years experience is preferred

Do you need Home Health Care Experience?

Growing Florida Home Care Organization

Team and family focused organization

Florida Nursing License LPN or RN compact accepted

Ability to review high volume documents with accuracy and efficiency

Required: Associate's degree or higher in Health Information Management

Intermediate to advanced proficiency in Microsoft applications (Word, Excel and Access), database management, and document preparation

REPORTS TO POSITION: Manager, Utilization Review

Required: Minimum 2 years’ experience in similar hospital related position with utilization experience preferred

Strong team working and collaborative skills

Strong analytical, problem solving and decision making skills

3 years - Clinical experience required

Working knowledge of URAC, NCQA and CMS accreditations

Excellent oral and written communication skills

Strong interpersonal and organizational skills

Ability to manage multiple projects and priorities

Superior interpersonal, client relations and problem-solving skills

Preferred experience includes Critical Care or Emergency Nursing RN.

Written and verbal communication skills

Knowledge of regulatory standards appropriate to position

Computer skills appropriate to position

Perform other duties as assigned by the supervisor including but not limited to processing concurrent denials.

401k match and additional yearly contribution

Assists departmental staff with issues related to coding, medical records/documentation, precertifications, reimbursement and claim denials/appeals.

MANAGING WORKLOADS: Manages completion of work assignments based on priority and due dates.

ORGANIZATION SKILLS: Organizes work to achieve maximum efficiency.

Prepares statistical analysis and utilization review reports as necessary.

Reviews admissions and service requests for prospective, concurrent, and retrospective medical necessity and/or compliance with reimbursement policy criteria.

Collaborates with onsite Clinical Effectiveness team regarding patient's discharge readiness.

Computer Skills Required: Data entry skills; Demonstrable skills with Google Docs, Google Sheets, and email applications.

Location FRANKLIN, TN (CHS Corporate)Full Time

Location FRANKLIN, TN (CHS Corporate)