UTILIZATION SPECIALIST

Southwest General; Middleburg Heights (OH); Hybrid; USD 80,000 - 110,000; Full time

Job summary

Southwest General is seeking an Utilization Specialist to conduct admission and concurrent stay screening reviews for eligible patients within the episode of care. The role ensures appropriate services, efficient resource use, and quality of care under guidelines.

Required are BSN or higher, five years of clinical nursing or related experience, and familiarity with screening criteria such as Interqual or MCG. Strong critical thinking and communication skills are essential.

Qualifications

• Graduation from an accredited School of Nursing. BSN graduate preferred.
• Minimum of five (5) years recent experience in clinical nursing or related nursing field (e.g. Utilization Review or Case Management).
• Previous Care Management, Case Management or Utilization Management Experience preferred
• Previous experience with screening criteria (i.e. Interqual, MCG) preferred
• Excellent critical thinking and communication skills

Responsibilities

• Carries out admission and concurrent stay screening reviews of assigned patients.
• Identify and support patients being placed in appropriate hospital level of care via admission processes.
• Communicate with physicians, hospital staff, insurance companies and patients regarding level of care and resource utilization.

Skills

Critical thinking

Communication

Education

BSN preferred

Bachelor's degree in Nursing

Job description

• Schedule, Shift, Hours PRN , Days , 8:00 AM -5:00 PM

The Utilization Specialist is responsible for carrying out admission and concurrent stay screening reviews of the assigned patient population during the episode of care under defined guidelines for acute care case management to ensure the appropriateness of services, utilization of hospital resources, and quality of care rendered. Accurate and efficient application of screening criteria will be applied to identify and support patients being placed in the appropriate hospital level of care via emergency, scheduled, or direct admission processes. Combines clinical, business, and regulatory knowledge and skill to reduce significant financial risk and exposure caused by concurrent and retrospective denial of payments for services provided. Through continuous assessments, problem identification, and education, the Utilization Specialist facilitates the quality of health care delivery in the most cost-effective manner. The Utilization Specialist must be able to demonstrate the knowledge and skills necessary to provide services appropriate to age groups according to specific chronological age, developmental age, and/or psycho-social maturity. The Utilization Specialist will work collaboratively with management, staff, and departments involved in the patient’s plan of care. The Utilization Specialist’s responsibility is to collect data and clinical review summaries on patients concurrently for both utilization review and quality assessment. The utilization data and clinical summaries are shared with insurance companies to obtain certification of days and prevent denial of payment for services. The Utilization Specialist will communicate with physicians, hospital staff, outside agencies such as insurance companies, and patients regarding the assigned level of care and associated resource utilization.

MINIMUM QUALIFICATIONS

Education:

Graduation from an accredited School of Nursing. BSN graduate preferred.

Required length and type of experience:

Minimum of five (5) years recent experience in clinical nursing or related nursing field. (e.g. Utilization Review or Case Management)

Previous Care Management, Case Management or Utilization Management Experience preferred

Previous experience with screening criteria (i.e. Interqual, MCG) preferred

Excellent critical thinking and communication skills

Required licensure, certification or registry:

Current licensure by Ohio State Board of Nursing.