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

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

Benefits offered by this job

Health, Dental and Vision plans

Matching retirement plans

Paid time off (PTO)

Education Assistance Program

Employee Assistance Program

Employee Referral Bonus Program

Discounted cafeteria meals

Parental Leave

Job summary

Great River Health is seeking a Utilization Review Specialist to review clinical documentation for medical necessity and certify admissions in alignment with CMS guidelines.

The role requires an AA nursing degree, active RN license (IBON) and 4–6 years in clinical settings with 1–3 years in Utilization Review. Bachelor’s in Nursing preferred. Schedule includes 8:00am–4:30pm with every 6th weekend; competitive compensation and benefits.

Qualifications

• Associate’s Degree (AA) in Nursing required.
• 4-6 years clinical experience.
• 1-3 years Utilization Review experience.
• Registered Nurse license with Iowa Board of Nursing (IBON) required.
• Bachelor’s Degree in Arts/Sciences (BA/BS) in Nursing preferred.

Responsibilities

• Review inpatient encounters for medical necessity and document review.
• Gather and analyze clinical documentation to support decisions.
• Monitor cases for medical necessity and level of care.
• Lead the Utilization Review team and daily huddles.
• Assist revenue cycle with claim corrections and appeals.

Skills

Clinical review

Medical record analysis

Communication

CMS guidance

Education

Associate’s Degree in Nursing (AA)

RN license (IBON)

Bachelor’s degree in Nursing preferred

Tools

Electronic Medical Records (EMR)

Job description

Minimum Hiring Wage:

From $90,064.00 a year

Job Details:

Scheduled Hours: 8:00am - 4:30pm | Every 6th Weekend 8:00am - 8:00pm

Job Description:

Associate’s Degree (AA) Nursing Required

• 4-6 years Require 4-6 years clinical experience Required
• 1-3 years Previous experience in Utilization Review Required
• Registered Nurse Iowa Board of Nursing (IBON) (United States of America) Required
• Bachelor’s Degree in Arts/Sciences (BA/BS) Nursing Preferred

Responsible 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 do

• Review 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 guidelines
• Respond to and assist the revenue cycle in claim correction. Submit appeals of denied claims. Follow up on appeals until there is resolution
• Lead the Utilization Review team in their daily tasks and daily huddles

Benefits:

We are excited to offer an aggressive compensation and benefits package for qualifying positions, which includes:

• Competitive base pay

• Matching retirement programs

• Health, Dental and Vision plans

• Health Savings and Flexible Spending Accounts

• Employee discounts including car rental, cell-phone plans

• Employer-paid, Long-Term Disability, Life, and AD&D

• Paid time off (PTO)

• Education Assistance Program

• Employee Assistance Program

• Employee Referral Bonus Program

• Discounted cafeteria meals

• Paid Parental Leave

• Employee Service Recognition program

• Voluntary plans including: Life, AD&D, Short-Term Disability, Critical Illness, Accident, Insurance, and Hospital Indemnity

Great 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.