Utilization Review Team Lead | 40 Hours per Week | Utilization Review

Great River Health Systems; West Burlington (IA); On-site; USD 81,000 - 99,000; Full time

Job summary

Great River Health Systems in West Burlington, IA, is seeking a Utilization Review Specialist to review clinical documentation in the EMR and certify admissions, ensuring compliance with CMS Conditions of Participation for Utilization Management.

The role leads the Utilization Review Team, coordinates daily huddles, and handles inpatient denials follow-up. Requires RN license, 4–6 years clinical and 1–3 years UM experience; BA/BS Nursing preferred. 8:00am–4:30pm, every 6th weekend 8:00am–8:00pm.

Qualifications

• AA nursing required
• 4-6 years clinical experience
• 1-3 years Utilization Review experience
• RN Iowa Board of Nursing (IBON) required
• BA/BS Nursing preferred

Responsibilities

• Review inpatient encounters for medical necessity.
• Gather and analyze clinical documentation to formulate an outcome.
• Make decisions based on facts and evidence; assume responsibility for those decisions.
• Monitor cases for medical necessity/level of care.
• Accurate input of data; manage multiple priorities.
• Lead the Utilization Review team in daily tasks and huddles.
• Submit appeals of denied claims and follow up until resolution.

Skills

Excellent communication skills

Education

Associate’s Degree in Nursing

Bachelor’s Degree in Nursing (BA/BS) preferred

Job description

Minimum Hiring Wage:From $90,064.00 a yearJob Details:Scheduled Hours: 8:00am - 4:30pm | Every 6th Weekend 8:00am - 8:00pmJob Description:Associate’s Degree (AA) Nursing Required4-6 years Require 4-6 years clinical experience Required1-3 years Previous experience in Utilization Review RequiredRegistered Nurse Iowa Board of Nursing (IBON) (United States of America) RequiredBachelor’s Degree in Arts/Sciences (BA/BS) Nursing PreferredResponsible for the review of clinical documentation in the Electronic Medical Record (EMR), comparing it to the nationally accepted and evidence-based criteria to certify an admission to the facility, and for concurrent/continued stay review as appropriate. Also responsible for maintaining compliance with the CMS Conditions of Participation for Utilization Management. The Utilization Review Team lead function as a Utilization Review Specialist. In addition, the Utilization Team lead will be responsible in completing and following up on inpatient denials. The team lead will lead daily huddles and act as a resource to the Utilization Review team.Qualifications:What you will doReview inpatient encounters for medical necessity-Accurate and timely record review.-Gather and analyze clinical documentation to formulate an outcome.-Making decisions based on facts and evidence; assuming responsibility for those decisions.-Monitor cases for medical necessity/level of care.-Accurate input of data.-Manage multiple priorities.-Remains current with medical and surgical procedures, products and general trends in health care delivery.-Adhere to all state and Federal regulations for all UM reviews.-Practice utilization management activities within the scope of practice.Excellent Communication Skills-Effective and appropriate communication with physicians and insurance providers for the medical necessity of healthcare services.-Work incoming calls from patients, insurances, providers and facilities promptly.-Cooperate and work effectively with all department and staff to facilitate services to members and providers of care.-Maintain continuous, effective communication with other departments/disciplines.-Effective communication with patients and families regarding level of care and CMS guidelinesRespond to and assist the revenue cycle in claim correction. Submit appeals of denied claims. Follow up on appeals until there is resolutionLead the Utilization Review team in their daily tasks and daily huddlesBenefits:We are excited to offer an aggressive compensation and benefits package for qualifying positions, which includes:Competitive base payMatching retirement programsHealth, Dental and Vision plansHealth Savings and Flexible Spending AccountsEmployee discounts including car rental, cell-phone plansEmployer-paid, Long-Term Disability, Life, and AD&DPaid time off (PTO)Education Assistance ProgramEmployee Assistance ProgramEmployee Referral Bonus ProgramDiscounted cafeteria mealsPaid Parental LeaveEmployee Service Recognition programVoluntary plans including: Life, AD&D, Short-Term Disability, Critical Illness, Accident, Insurance, and Hospital IndemnityGreat River Health and its affiliates are Equal Opportunity employers. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity and expression, age, national origin, mental or physical disability, genetic information, veteran status, or any other status protected by federal, state, or local law.