Hospital Utilization Review Specialist

MCS Puerto Rico; San Juan (PR); On-site; USD 48,000 - 68,000; Full time

Job summary

MCS Puerto Rico in San Juan is seeking a registered nurse to evaluate utilization in clinical records and hospital facilities, performing concurrent and retrospective reviews and coordinating with Case Management and other departments.

The role requires a Bachelor's in Nursing, at least one year of clinical experience, and current Puerto Rico nursing license and driver's license; Spanish and English proficiency are required.

Qualifications

• Bachelor's Degree in Nursing is required.
• At least 1 year of experience in a clinical area and reviewing hospital utilization.
• Nurse license and Puerto Rico nursing professionals license/registration required.
• Driver's License valid in Puerto Rico required.
• Languages: Spanish and English advanced.

Responsibilities

• Visits hospitals and health facilities to assess utilization in clinical records using guidelines and procedures.
• Performs daily audit entries and verifies closed cases in electronic systems.
• Evaluate justification of services and notify management of irregular utilization patterns.
• Identify and report cases with potential risks to other departments for alternative treatment planning.
• Identify, intervene, and suggest care alternatives to coordinate patient discharge plans.
• Participate in special projects and ensure compliance with corporate policies and CMS guidelines.

Skills

Nursing

Education

Bachelor's Degree in Nursing

Job description

GENERAL DESCRIPTION

Evaluates utilization in clinical records and hospital facilities concurrently and retrospectively. Identifies and refers to other clinical departments (Case management, condition management, among others) cases for the management of treatment alternatives. Makes efforts to receive advice in difficult situations in cases under evaluation.

Regular

Exempt

GENERAL DESCRIPTION

Evaluates utilization in clinical records and hospital facilities concurrently and retrospectively. Identifies and refers to other clinical departments (Case management, condition management, among others) cases for the management of treatment alternatives. Makes efforts to receive advice in difficult situations in cases under evaluation.

ESSENTIAL FUNCTIONS

• Visits hospitals and health facilities to assess utilization concurrently or retrospectively in clinical records using clinical guidelines and procedures established by the Clinical Affairs department.
• Performs daily audit entries and verifies closed cases in electronic systems.
• Evaluate the justification of the services provided and notify of and refer to management of any irregular utilization patterns to ensure the services' quality.
• Identifies and reports cases with potential risks to other clinical departments for managing alternative treatment alternatives, case management in extended stays, or readmissions following established guidelines and procedures.
• Identifies, intervenes, and suggests care alternatives to the provider to coordinate the patient discharge plan.
• Participates in special projects assigned to the department and as required.
• Compliance with the operational standards established by the Clinical Affairs department and CMS guidelines.
• Must comply fully and consistently with all company policies and procedures, with local and federal laws as well as with the regulations applicable to our Industry, to maintain appropriate business and employment practices.
• May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document.

MINIMUM QUALIFICATIONS

Education and Experience: Bachelor's Degree in Nursing. At least one (1) year of experience working in a clinical area and reviewing hospital utilization, preferably in the Health Insurance Industry.

Certifications / Licenses: A valid Nurse & Association Nursing Professionals of Puerto Rico License and Registration is required. A Driver's License valid in the Commonwealth of Puerto Rico is required.

Other: N/A

Languages: Spanish – Advanced (comprehensive, writing and verbal)

Language: English – Advanced (comprehensive, writing and verbal)

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