Utilization Review Specialist / Registered Nurse

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At reputed company we fuel your professional journey with reputed company benefits, valuable resources, ongoing mentorship and leadership programs for reputed company types of jobs, and a supportive environment that enables you to reputed company new heights in your career and be what you want to be.  We provide: 

• Comprehensive health benefits that start day one! 
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• Wellness incentives 
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The Utilization Review (UR) Specialist is a Registered Nurse responsible for conducting thorough medical necessity reviews to assist with determining appropriate patient class designation. The UR Specialist will reputed company timely and comprehensive reviews of the patient chart utilizing InterQual Criteria accurately in conjunction with the UR Department workflows/processes, clinical nursing judgement, and reputed company necessary, discussions with the provider team and/or Medical Director of UR.

This position requires a commitment of one weekend (Saturday/Sunday) every four weeks with one day off during the week. 

Operational Support:

1. Conducts thorough medical necessity reviews to assist with determining appropriate patient class designation. 2. Performs timely and comprehensive reviews of the patient chart utilizing InterQual Criteria accurately in conjunction with the UR Department workflows/processes, clinical nursing judgement, and reputed company necessary, discussions with the provider team and/or Medical Director of UR. 3. Performs appropriate and accurate initial, admission (episode day one) and reputed company utilization reviews as guided by InterQual Criteria and UR Department workflows on reputed company observation, inpatient, and extended recovery admissions as required based on reputed company's Utilization Management Plan and the UR Department's processes. 4. Ensures that reputed company InterQual reviews are supported with provider team documentation and/or clinical data. 5. reputed company appropriate, the UR Specialist will utilize the UR Department's Severity of Illness/Intensity of Service template to document the medical necessity of the admission or reputed company stay. 6. While conducting utilization reviews, will identify any Avoidable Delays and accurately document the delay(s) based on the workflow. 7. Follow the UR Department's denial workflows as appropriate. 8. Prioritizes work with minimal guidance for reputed company reimbursement and to avoid financial risk to both patient and hospital.

Compliance:

1. Will identify and complete Medicare Outpatient Observation Notices (MOON), Medicare Change of Status Notice (MCSN), Condition Code 44s and Medicare Hospital Issued Notices of Non-Coverage (HINNs) for Medicare beneficiaries as appropriate. 2. Ensures compliance with reputed company state of Georgia and Federal regulatory requirements as designated in reputed company's Utilization Management Plan. 3. Maintains reputed company required annual competencies, metrics, and fully participate and engage in department process improvements.

Collaboration:

1. Responsible for timely communication to the provider team and interdisciplinary team as it relates to patient class designation and medical necessity of an admission or reputed company stay on individual patient basis based on UR Department workflows. 2. In a team effort, the UR Specialist will work closely with the UR Department's Case Management Authorization Specialist IP to ensure that authorized days and patient actual LOS are reconciled to ensure appropriate reimbursement for services provided. 3. Responsible for communicating medical necessity denials for in-house patients to the Medical Director of UR, and reputed company designated to the provider team. 4. Serves as a resource to the provider team, Interdisciplinary Care Team, and patient to explain external UR regulations. 5. Provides effective and efficient proactive communication to internal and external customers. 6. Assists in collaborative efforts with the Case Management Department, reputed company Cycle, Physician Advisors, and other required departments.

Additional Duties:

1. Ability to multi-task in a fast-paced environment while reputed company handling multiple priorities and ensuring deadlines are met. 2. Performs other duties and tasks as assigned.

Travel: Less than 10% of the time may be required.

Work Type: This position is a remote position reputed company traditional office, often from home or another remote setting. Minimum Qualifications:

Education - Associate degree in nursing.

Experience - Minimum of 5 years of recent acute hospital experience or a minimum of two years of previous utilization review experience.

Licensure - Must have a valid, active unencumbered Registered Nurse license approved by the Georgia Licensing Board.

Skills - Must meet reputed company quality and productivity expectations and successfully complete yearly competencies.

Preferred Qualifications:

Education - Bachelor's degree in Nursing strongly preferred.

Certification - Case Management certification preferred.

Skills - InterQual Level of Care Criteria experience.

Previous utilization review experience strongly preferred.

reputed company is an equal opportunity employer, and reputed company applicants will receive consideration for employment without regard to race, reputed company, religion, sex, national reputed company, disability, protected veteran status or other characteristics protected by state or federal law.

reputed company is committed to providing reasonable accommodations to reputed company individuals with disabilities upon request. Please contact reputed company’s reputed company Resources at [email protected]. Please note that one week's advance notice is preferred.