Location: Nyack,NY, USA
The Utilization Review Specialist comprehensively plans with the health care team to ensure patient needs are met and care delivery is coordinated across the continuum of the various managed care systems. Will regularly collaborate with Physicians and peers regarding service barriers that may need further followup. Identifies and works to eliminate/minimize system variation and service delivery barriers that prevent payments and the achievement of optimal patient outcomes in the expected time frame and with the most efficient utilization of resources. Carries out activities related to utilization management including following up on denial claims which sometimes require continuous follow up, speaking over the phone to managed care carriers, discharge planning, care coordination and referral to other levels of care. Performs as an integral part of the interdisciplinary team promotion interdisciplinary collaboration. Facilitates assignment of level of care, consider payer requirements and responds accordingly to avoid adverse financial consequence to the patient and the hospital. Provides superior customer service by modeling the We Care Standards. QUALIFICATIONS A Bachelor's Degree required in Nursing. Three to five years relevant clinical medical surgical, ICU or ER experience preferred. Experience and thorough understanding of performing utilization review, investigating denial claims, follow up and discharge planning preferred. This position is very different from an RN Case Manager. Training/Certification: HC-PRI certified and PRI screen preferred. Licensure: Current NYS RN license required Other: Qualities include effective written and verbal communication skills, decision making and problem solving skills and insurance carrier comprehensive assessment skills. Must be detail orientated. Must be comfortable with investigating outcomes and communicating with Physicians, physician extenders, and managed care systems over the phone and online.