UTIL REVIEW SPEC

Overview

To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values—integrity, patient-centered, respect, accountability, and compassion—must guide what we do, as individuals and professionals, every day.

 

JOB SUMMARY

The Utilization Review Specialist (URS) performs utilization review activities as pertains to medical necessity of admissions for all patients in accordance with established guidelines, and stewards the process of ensuring regulatory and financial compliance of resource utilization, documentation and physician orders.

EEO/AA/Disability/Veteran

Responsibilities

  • 1. Functions as the liaison between various hospital departments, medical staff and payers on issues issues related to medical necessity for admission and continued stay.
  • 2. The URS maintains open, transparent and clear lines of communication with the physician advisers.
  • 3. Provides UM education to clinical staff as needed.
  • 4. Applies standardized criteria and guidelines to assist in the determination of appropriateness of admissions and assignment of patient class (i.e. observation, inpatient and outpatient).
  • 5. Assist in monitoring wasted resources while maintaining uncompromisingly high quality of care. Responsible for maintaining and ensuring the admission process remains fully compliant with Medicare and Medicaid regulations.
  • 6. Acts as a resource to Care Management department regarding utilization, insurance and payer issues.
  • 7. Identifies potential problems regarding payment eligibility for clinical services and recommends corrective action.

Qualifications

EDUCATION

 

Minimum of a baccalaureate degree in a clinically related field. RN required.

 

EXPERIENCE

 

Minimum of five (5) years of relevant clinical experience is required, with at least two (2) years of experience in case management, care coordination, utilization review, or disease management preferred.

 

LICENSURE

 

Current RN licensure in Connecticut

 

SPECIAL SKILLS

 

The applicant must have a high degree of familiarity with clinical care to establish credibility with physicians, LIPs, nurses and other members of the front-line care team. The URS must have strong interpersonal and communication skills to manage competing priorities of the different stakeholders to ensure provision of high quality, high value and efficient care. The URS will regularly interact with physicians and nurses, and must be able to assertively express oneself without antagonizing the other members of the interdisciplinary team. The URS must have the ability to quickly process complex problems, identify key components, and develop plans for resolution. The applicant must be able to provide clinical and financial education to colleagues, patients and families. Critical thinking, negotiation and the ability to set priorities are of highest importance. Must be able to learn and use multiple computer systems. Must be able to work independently and as part of a team.

 


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