Rn Specialist - Utilization Mgmt: Corp - Utilization Review

Summary

Ensures that services are delivered in a manner that balances quality of care with efficiency, cost-containment and compliance.

Detailed Responsibilities

• Collaborates with onsite Clinical Effectiveness team regarding patient's discharge readiness.
• Prepares statistical analysis and utilization review reports as necessary.
• Assists departmental staff with issues related to coding, medical records/documentation, precertifications, reimbursement and claim denials/appeals.
• Reviews admissions and service requests for prospective, concurrent, and retrospective medical necessity and/or compliance with reimbursement policy criteria.

Essential

Competencies and skills:

• PATIENT AND FAMILY CENTERED CARE: "Provides Patient and Family Centered Care to patients, families, visitors and internal customers"
• ORGANIZATION SKILLS: Organizes work to achieve maximum efficiency.
• MANAGING WORKLOADS: Manages completion of work assignments based on priority and due dates.
• CUSTOMER SERVICE: Demonstrates commitment to service excellence by promptly addressing internal/external customer issues/requests, resolving concerns while maintaining a professional image and behavior to build and enhance the patient/family/customer experience.
• ACCOUNTABILITY: Accepts ownership of job roles and specific assignments/goals; works independently, takes responsibility for own actions; admits mistakes and judgment errors; and accepts constructive feedback. Connects personal work results to the accomplishment of team and organizational goals.
• UTILIZATION REVIEW: Ensures that services are delivered in a manner that balances quality of care with efficiency, cost-containment and compliance.
• STANDARDS OF BEHAVIOR: Acts in a manner that supports the standards of communication, respect, privacy, and teamwork by demonstrating a commitment to professional and ethical conduct.
• ACCURACY: Completes work assignments within established quality and/or quantity standards.
• RESPONDING TO CHANGE: Accepts change and adapts in a positive and productive manner; handles unexpected situations and changes in direction calmly and with confidence. Views new assignments and job responsibilities as an opportunity for growth.
• PROBLEM SOLVING: Ability to identify, analyze and effectively solve problems.

Education

Essential:

• Accredited Program

Essential

Education specialization:

• Nursing

Credentials

Essential:

• Registered Nurse License

Other Information

Complexity of Work: Requires critical thinking skills, decisive judgment and the ability to work with minimal supervision. Must be able to work in a stressful environment and take appropriate action. Computer literate and utilizes a variety of criteria based applications. Excellent interpersonal skills needed.

Required Work Experience: 3 years of clinical experience.

Essential

Working conditions:

• Repetitive Movement Hand/Arm 60.00%
• Keyboard Entry 100.00%
• Seeing - Far 40.00%
• Bending and Stooping 40.00%
• Computer Monitor 80.00%
• Audible Speech 80.00%
• Dust 60.00%
• Reaching 60.00%
• Lifting or Carrying 0 - 25 lbs Non-Patient 40.00%
• Hearing Acuity 80.00%
• Depth Perception 80.00%
• Seeing - Near 80.00%
• Distinguish Color 40.00%
• Sitting 80.00%

Organizational Profile

Memorial Healthcare System, consisting of 6 acute care hospitals, a nursing home, outpatient facilities, home health services and physician practices, provides quality, comprehensive care to the residents of the surrounding communities. We invite you to join one of the nation's leading healthcare systems, recognized for use of advanced technology and clinical informatics.

Memorial Support Services provides a variety of business services to support our facilities. The main offices are located in Miramar with satellite offices located throughout our system.

Disclaimer: This job description is not intended, nor should it be construed to be an exhaustive list of all responsibilities, skills, efforts or working conditions associated with the job. It is intended to indicate the general nature and level of work performed by employees within this classification.