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Utilization Review SpecialistJob ID 18-815 Date posted 09/20/2018
JOB SUMMARY Contributes to the Hospital's mission by providing our patients with a safe plan of care for discharge. This professional licensed position will have an impact on finance and growth by classifying patients' status appropriately and maintaining a 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.
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 experience
• 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
LICENSES, REGISTRATIONS, CERTIFICATIONS Required
• Current license to practice professional nursing from MA Board of Registration
• Case Management certification
OTHER JOB REQUIREMENTS Professional Commitment Requirements:
Keep abreast of developments in the field and/or licensure through continuing education, participation in professional organizations or a combination of both.
On-call: Off-shift coverage rotation expected
Schedule requirements: Holiday rotation and occasional weekend coverage required
Travel requirements: N/A
The Utilization Review Specialist is an RN who works with physicians, the payers and inpatient case management team to validate the medical necessity of the hospital care. Using the concepts of utilization review, clinical documentation improvement and revenue integrity, these specialized case managers analyze medical documentation to ensure that proper reimbursement will be achieved in coordination to the intensity of medical care provided. the Utilization Review Specialist also works closely with the team to mitigate, track and follow up on current and potential denials.