Utilization Review Specialist

Hunterdon Healthcare; Flemington (NJ); On-site; USD 60,000 - 80,000; Full time

Job summary

An established industry player in healthcare is seeking a Utilization Review Specialist to ensure the appropriate use of hospital services and improve patient care quality. In this role, you will monitor hospital admissions and extended stays, applying evidence-based criteria to evaluate the necessity of healthcare services. Collaborating with medical and clinical staff, you will enhance documentation practices and ensure compliance with regulations. This position offers a chance to make a significant impact on patient care within a supportive and community-focused environment, making it an exciting opportunity for qualified nursing professionals.

Qualifications

• Bachelor's Degree in nursing or proof of enrollment in a BSN program required.
• Three years of medical/surgical hospital-based direct patient care experience.

Responsibilities

• Monitor adherence to utilization review plans and ensure effective use of hospital services.
• Work with clinical staff to improve documentation quality and compliance.

Skills

Verbal Communication

Written Communication

Organizational Skills

Interpersonal Skills

Patient Care Evaluation

Data Analysis

Education

Bachelor's Degree in Nursing

Associate's Degree in Nursing

Tools

Milliman Care Guidelines

Job description

The Utilization Review Specialist monitors adherence to the hospital's utilization review plan to ensure the effective and efficient use of hospital services and monitors the appropriateness of hospital admissions and extended hospital stays. The evaluation of the appropriateness and medical necessity of health care services, procedures, and facilities is conducted through the application of evidence-based criteria or guidelines, and through authorization/prior authorization under the provisions of an applicable health insurance plan.

Primary Position Responsibilities

1. Performs utilization activities, using Milliman Care Guidelines under the guidance of the Physician Advisor, to provide clinical information to payors as requested and ensures correct status of all patients to insure maximum reimbursement.
2. Works with medical and clinical staff to improve overall quality and completeness of clinical documentation.
3. Communicates and educates medical, clinical and coding staff of trends and opportunities for improvement.
4. Tracks and trends all queries presented to medical and clinical staff.
5. Follows department policies to remain in compliance with State and Federal regulations.
6. Other duties as assigned.

Work Contact Group (Internal/External)

HMC employees, medical/clinical staff, department co-workers, providers, insurance reviewers.

Reporting Relationships

Reports to (position): Director Care Coordination

Qualifications

Required: All hires after July 2012 are required to have a Bachelor's Degree in nursing OR if Associates Degree or Diploma, RN must provide proof of enrollment in a BSN program prior to hire, be continuously enrolled and complete within 5 years of hire date or internal RN promotion date.

Preferred:

Minimum Years of Experience (Amount, Type and Variation)

Required: Three years of medical/surgical hospital based direct patient care experience.

Preferred: Five years of medical/surgical hospital based direct patient care experience.

License, Registry or Certification

Required: Current NJ RN Licensure.

Knowledge, Skills and/or Abilities

Required: Excellent verbal, written, organizational and interpersonal skills. Demonstrates experience in patient care evaluation methodologies, analysis and reporting of patient clinical data to various payee sources using Miliman Care Guideline criteria sets.

Preferred: None

About the company

Hunterdon Healthcare is committed to providing a full range of quality health and medical services that respond to the needs of the northwest New Jersey community.