Clinical Utilization Review Specialist II

St. Mary's General Hospital; Passaic (NJ); On-site; USD 36,000 - 56,000; Full time

Job summary

St. Mary's General Hospital in Passaic, NJ is seeking an experienced Utilization Review Coordinator to coordinate clinical reviews, work with the CMO, and support case management and UR meetings.

You will review patient charts for admission criteria, gather data for payers, coordinate discharge referrals, and ensure compliance with Federal and State guidelines, while advising departments and maintaining independent judgment.

Qualifications

• Medical Graduate, Dental Graduate, PA, or Nursing Graduate required.
• Two years of Utilization Review experience as a Medical Review Coordinator – I required.
• Knowledge of Clinical Pathophysiology and Pharmacology required.
• ECFMG Certification And/or Bachelor’s or higher from a US-based accredited institution in a Health and Human Services field is highly preferred.
• Master of Public Health (MPH) or post-graduation in a related health care field preferred.
• Clinical experience in acute care setting preferred.
• Excellent written and verbal communication skills.
• Excellent interpersonal skills to build effective partnering relationships with physicians, nurse staff, coding staff and hospital management staff.
• Ability to work independently in a time-oriented environment.
• Computer data entry with 10-key preferred, with accurate typing speed of 35 wpm preferred.

Responsibilities

• Coordinate and complete clinical reviews for patient medical records.
• Work closely with CMO and participate in Case Management and UR meetings.
• Serve as ongoing educator to all departments.
• Review patient charts to assess admission and continuation criteria; gather data for payers/fiscal intermediaries.
• Coordinate discharge referrals as requested by clinical staff, payers, patients, and families.
• Maintain independence and apply knowledge of Federal, State, and intermediary guidelines.

Skills

Utilization Review

Communication skills

Independent judgment

Education

Medical/Dental/PA/Nursing degree

ECFMG Certification

Bachelor’s or higher in Health & Human Services

Master of Public Health (MPH)

Tools

10-key data entry

Job description

St. Mary's General Hospital in Passaic, NJ is seeking an experienced Utilization Review Coordinator to coordinate clinical reviews, work with the CMO, and support case management and UR meetings.

You will review patient charts for admission criteria, gather data for payers, coordinate discharge referrals, and ensure compliance with Federal and State guidelines, while advising departments and maintaining independent judgment.