PRN Clinical Utilization Review Specialist

Tennova Healthcare- Turkey Creek Medical Center; États-Unis; À distance; USD 70 000 - 100 000; Plein temps

Résumé du poste

Tennova Healthcare- Turkey Creek Medical Center is seeking a PRN Remote Clinical Utilization Review Specialist to evaluate the necessity and efficiency of hospital services and to support payer requirements. You will review admissions and continued stays, collaborate with physicians to gather documentation for medical necessity, and document all activities in the case management system.

You will work with insurance providers to secure approvals and resolve denials, while upholding HIPAA and

Qualifications

• 2-4 years of clinical experience in utilization review, case management, or acute care nursing.
• 1-3 years in care management preferred.
• 1-2 years in utilization management, payer relations, or hospital revenue cycle preferred.

Responsabilités

• Performs admission and continued stay reviews using evidence-based criteria to ensure appropriate utilization.
• Collaborates with physicians to obtain documentation for medical necessity, discharge planning, and payer requirements.
• Documents all utilization review activities in the hospital’s case management software, including reviews, escalations, and authorization details.
• Secures coverage approvals and mitigates denials by submitting reconsiderations or coordinating peer-to-peer reviews.
• Communicates with utilization review coordinators, case managers, and discharge planners to ensure a collaborative approach to patient care.
• Analyzes trends in admissions and extended stays to identify opportunities for process improvements.

Connaissances

Utilization management

Case management

EHR systems

HIPAA compliance

Communication skills

Analytical thinking

Formation

Practical Nursing (LPN)

Associate Degree in Nursing (ADN)

Nurse licensure

Outils

Case management software

Electronic Health Records (EHR)

Description du poste

Job Summary

The PRN Remote Clinical Utilization Review Specialist is responsible for evaluating the necessity, appropriateness, and efficiency of hospital services to ensure compliance with utilization management policies. This role conducts admission and continued stay reviews, supports denials and appeals activities, and collaborates with healthcare providers to facilitate efficient patient care. The Clinical Utilization Review Specialist monitors adherence to hospital utilization review plans and works to optimize hospital resource utilization, reduce readmissions, and maintain compliance with payer requirements.

The PRN Remote Clinical Utilization Review Specialist is responsible for evaluating the necessity, appropriateness, and efficiency of hospital services to ensure compliance with utilization management policies. This role conducts admission and continued stay reviews, supports denials and appeals activities, and collaborates with healthcare providers to facilitate efficient patient care. The Clinical Utilization Review Specialist monitors adherence to hospital utilization review plans and works to optimize hospital resource utilization, reduce readmissions, and maintain compliance with payer requirements.

Essential Functions

• Performs admission and continued stay reviews using evidence-based criteria, clinical expertise, and regulatory guidelines to ensure appropriate utilization of hospital services.
• Collaborates with physicians and clinical teams to obtain necessary documentation for medical necessity, discharge planning, and payer requirements.
• Documents all utilization review activities in the hospital’s case management software, including clinical reviews, escalations, avoidable days, payer communications, and authorization details.
• Works with insurance companies to secure coverage approvals and mitigate concurrent denials by submitting reconsiderations or coordinating peer-to-peer reviews.
• Communicates effectively with utilization review coordinators, case managers, and discharge planners to ensure a collaborative approach to patient care.
• Analyzes trends in hospital admissions and extended stays, identifying opportunities for process improvements to enhance utilization management.
• Serves as a key contact for facility staff and insurance representatives regarding utilization review concerns.
• Supports training initiatives within the department and escalates complex issues to management as needed.
• Performs other duties as assigned.
• Maintains regular and reliable attendance.
• Complies with all policies and standards.

Qualifications

• Technical School in Practical Nursing required or
• Associate Degree in Nursing required
• 2-4 years of clinical experience in utilization review, case management, or acute care nursing required
• 1-3 years work experience in care management preferred
• 1-2 years of experience in utilization management, payer relations, or hospital revenue cycle preferred

Knowledge, Skills And Abilities

• Strong knowledge of utilization management principles, payer guidelines, and regulatory requirements.
• Proficiency in case management software and electronic health records (EHR).
• Excellent communication and collaboration skills to work effectively with interdisciplinary teams and external payers.
• Strong analytical and problem-solving skills to assess utilization trends and optimize hospital resource use.
• Ability to work in a fast-paced environment while maintaining attention to detail and accuracy.
• Knowledge of HIPAA regulations and patient confidentiality standards.

Licenses and Certifications

• LPN - Licensed Practical Nurse - State Licensure required or
• RN - Registered Nurse - State Licensure and/or Compact State Licensure required
• CCM - Certified Case Manager preferred or
• Accredited Case Manager (ACM) preferred