RN - Utilization Review Specialist PRN - SSO Utilization Review - USA Health Shared Services

USA Health; Mobile (AL); On-site; USD 70,000 - 100,000; Full time

Job summary

USA Health in Mobile, AL is seeking a dedicated Utilization Review Nurse to join our team. You will review medical records, determine appropriate level of care, and collaborates with physicians, nurses, and payors to ensure compliant, timely, and cost-effective patient care.

The role requires RN licensure and 2 years of nursing experience; a Bachelor’s or Master’s in Nursing is preferred. Prior Utilization Review experience is a plus, and you will help maintain accurate documentation within the

Qualifications

• Graduation from an accredited nursing program with 2 years of professional nursing experience.
• Bachelor's or Master's degree in nursing preferred.
• Utilization Review experience preferred.
• RN licensure required in Alabama or compact state.
• Education/experience may substitute for other requirements.

Responsibilities

• Performs utilization review activities per policy and payor requirements, including reviews and prior authorizations.
• Analyzes medical records to support reviews.
• Collaborates with care teams to plan safe discharge and timely inpatient flow.
• Ensures optimal reimbursement through proper utilization review processes.
• Communicates with providers by phone, in person, and email.
• Maintains documentation and participates in performance improvement activities.

Skills

2 years nursing experience

RN licensure

Utilization Review

Education

Bachelor's Degree in Nursing

Master's Degree in Nursing

Tools

Hospital Information System

Job description

USA Health is Transforming Medicine along the Gulf Coast to care for the unique needs of our community. USA Health is changing how medical care, education, and research impact the health of people who live in Mobile and the surrounding area. Our team of doctors, advanced care providers, nurses, therapists, and researchers provides the region's most advanced medicine at multiple facilities, campuses, clinics, and classrooms. We offer patients convenient access to innovative treatments and advancements that improve the health and overall well-being of our community.

USA Health is Transforming Medicine along the Gulf Coast to care for the unique needs of our community. USA Health is changing how medical care, education, and research impact the health of people who live in Mobile and the surrounding area. Our team of doctors, advanced care providers, nurses, therapists, and researchers provides the region's most advanced medicine at multiple facilities, campuses, clinics, and classrooms. We offer patients convenient access to innovative treatments and advancements that improve the health and overall well-being of our community.

Responsibilities

• Responsibilities Performs functions independently, according to policy and third party payor requirements, to include: quality reviews, prior authorizations, initial/admission reviews, continued stay reviews, discharge reviews, retrospective reviews, appeals as appropriate for denials, and case management reviews for DRG payors
• Analyzes medical record data to complete functions
• Collaborates with members of the healthcare team, patients, families, and managed care workers to formulate appropriate discharge plans and promote a safe and timely flow through inpatient setting
• Ensures optimal reimbursement from third party payors through appropriate implementation of Utilization Review functions
• Communicates with healthcare providers via telephone, in person, and email (i.e., discussion with physicians regarding plan of care, length of stay, and stay type)
• Establishes and maintains a professional relationship with third party payor representatives
• Participates in interdisciplinary patient care meetings as assigned
• Utilizes a PC to access the Hospital Information System
• Enhances professional growth and development through participation in educational programs
• Completes annual education on nationally recognized level of care criteria
• Participates in all Utilization Review audit activities as assigned
• Orients new staff to the Utilization Review process as assigned
• Reports quality of care concerns discovered during Utilization Review functions to the Director
• Evaluates chart documentation for completeness relative to current ICD requirements and communicates deficiencies
• Demonstrates proficiency in Early Periodic Screening Diagnosis and Treatment (EPSDT) by performing independently, according to regulatory requirements, the following functions as assigned
• Identification of patient eligibility, collection of data required to perform screening, performance of Inter-periodic Screening Components, and communication of screening findings to all related parties
• Maintains accurate and complete records both written and via personal computer
• Documents reviews according to hospital policy
• Completes/documents forms/requests from third party payors and regulatory parties
• Documents variances, discharge plans and EPSDT functions
• Utilizes proper body mechanics when moving equipment that is necessary to perform essential functions
• Communicates and uses appropriate customer relation skills with physicians, patients, families and healthcare team in person and via telephone
• Responds to overhead pages
• Accesses and accurately maintains electronic and paper medical records
• Participates on committees as assigned
• Participates in Performance Improvement activities as assigned
• Completes all mandatory department, educational and hospital requirements
• Adheres to current Infection Control and Safety Standards
• Regular and prompt attendance
• Ability to work schedule as defined and overtime as required
• Related duties as assigned

Additional Information

Employees must be in a regular position, working 20 hours or more per week (.50 FTE or greater) to qualify for benefits.

Qualifications

• Graduation from an accredited school of nursing meeting the minimum standards set by the State of Alabama and 2 years or professional nursing experience Required
• Bachelor's Degree or Master's Degree in nursing Preferred
• Utilization Review experience Preferred
• RN - Registered Nurse - State Licensure and/or Compact State Licensure Required
• Comparable combination of education and experience may substitute for the above requirements.

Equal Employment Opportunity/Affirmative Action Employer

The University of South Alabama is an Equal Opportunity Employer and does not discriminate on the basis of race, color, national origin, sex, pregnancy, sexual orientation, gender identity, gender expression, religion, age, genetic information, disability, protected veteran status or any other applicable legally protected basis. EO Employer - minorities/females/veterans/disabilities/sexual orientation/gender identity.