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Utilization Management Specialist

Job ID 18-753 Date posted 07/26/2018

Contributes to the Hospital's mission by supporting proper classification and a safe plan of care. This professional licensed position will have an impact on finance and growth by classifying patients' status appropriately and supporting a care plan to maintain an expected length of stay within budget. They will impact the patient experience and quality of care by daily rounding and working with the patient/family to establish the best plan of care for discharge.
The Utilization Management Specialist promotes the documentation of medical necessity and resource consumption during an inpatient hospitalization.

The candidate will perform medical necessity surveillance, conducts concurrent clinical reviews, manages patient status and integrates financial with clinical to ensure proper reimbursement.

The candidate initiates provider concurrent and retrospective queries as supported by medical record documentation to improve the accuracy, integrity and quality of patient data, and improve the quality of the physician documentation within the body of the medical record. The candidate collaborates with all members of the case management department, unit managers, physicians and physician groups, staff nurses, coding staff and other team members. This role requires the ability to educate and present in both formal and informal venues for the purposes of hospital-wide compliance and continual performance improvement.
This position works in tandem with the case management department and may be called upon at any time to function in the role of case manager/care coordinator to accommodate departmental needs.

Hired Prior to 10/1/13: Graduate of a state approved and/or accredited RN program.
Hired On or After 10/1/13: Bachelors' degree in Nursing ( BSN ) or obtain BSN within 5 years of hire

BSN upon hire

• At least five (5) years of clinical experience as a Registered Nurse
• Previous Case Management or Utilization Reviewer experience
  • Experience educating and/or presenting
Other Skills/Knowledge
• For safety and quality reasons, must be able to read, write and communicate effectively in English with patients, visitors, vendors, and fellow members of the hospital team.
• Computer skills
• InterQual Criteria

• Current license to practice professional nursing from MA Board of Registration