JOB SUMMARY

Utilization Review (UR) Specialist focuses on integrating case management, social services, discharge planning, and utilization review and pre- and post-hospital services to ensure clinical efficacy and best outcomes for patients. Monitors patient charts and records to evaluate care concurrent with patient’s treatment. Reviews status of approvals from insurers. Collects and complies data as required and according to applicable policies and regulations. Consults with nurses and physicians as needed. Position is non-RN. Typically reports to the department head. Serves as administrative support to the Case Management/Utilization Review.

ESSENTIAL FUNCTIONS

• Completes assessment of patient and family needs under supervision of RN Case Manager or Social Worker to facilitate identification psychosocial, financial, and discharge needs.


• Verifies patient demographics.


• Collaborates with physician, nurses, and other disciplines involved with the care of the patient to foster a coordinated approach to patient care. Communicates with providers regarding the medical plan of care, anticipated discharge, and consideration of alternative setting.


• Facilities and stewards process issues to avoid delays in patient care. Intervenes with appropriate individuals/department about service delays that may impact quality of care and/or length of stay.


• Serves as administrative support to the Case Management and Utilization Review department and as a float to ensure patient needs are met.


• Distributes Medicare Beneficiary Notes (IMM, MOON, MCSN, etc.) to patients and complete required documentation to meet regulatory standards.


• Participates in providing documentation necessary for insurer medical reviews in collaboration with the utilization review team.


• Completes all data entry and other administrative tasks within prescribed timeframes. Performs administrative duties necessity to facilitate placement, discharge care coordination, and other information sharing with community partners and resources.


• Maintains good working relationships both within departments and with other departments.


• Collaborates with patient accounting, eligibility specialist and outpatient billing to optimize captured services.


• Maintains required and concise documentation for patients including physical and functional limitations, psychosocial characteristics, plan of care to address post-hospital, treatment, and post treatment care needs, educational needs, and involvement in planning for care of patient and family, family/social support systems, financial, economic, and discharged needs. Initiates referrals to disciplines with appropriate paperwork.


• Other duties as assigned. This list is non-exhaustive.

JOB QUALIFICATIONS

• Education
  
  
  
  
  • Associate degree or its equivalent is preferred.
  
  
  
  


• Licensure
  
  
  
  • None required.
  
  
  
  


• Certifications required
  
  
  
  • Medicare navigator highly encouraged.
  
  
  • See Cardiopulmonary Resuscitation Certification Policy and Certifications/Education Requirements Policy.
  
  
  
  


• Experience
  
  
  
  • Three years of experience in the healthcare field preferred.
  
  
  
  

Knowledge, Skills, and Abilities

• The ability to maintain continuing education requirements and all certifications and licenses as required (e.g., ACLS, PALS, TEAM, CPR)


• Excellent verbal communication skills: ability to mediate and interact with people from diverse populations.


• Able to assess, appraise, evaluate, and understand complex and technical health concepts and client functioning.


• Ability to define problems, collect data, establish facts, and draw conclusions.


• Ability to apply concepts of fractions, percentages, ratios, proportions to practical situations.


• Ability to perform multiple tasks simultaneously with frequent interruptions and under stressful conditions.


• Analytical and reasoning skills with a high level of mental concentration and memory.


• Ability to interact positively with patients, patient families, physicians, and staff to effectively care for the patients.


• Computer Knowledge including the ability to enter material into electronic records. Ability to operate fax, computer, and copy machine to perform the duties of the position.


• The ability to demonstrate knowledge of developmental stages and apply developmental theories/concepts when planning and implementing care for the appropriate age of the patient. Ability to maintain the appropriate level of knowledge and skills.


• Must demonstrate and maintain current knowledge and skill in the following age groups:
  
  
  
  • Infant (Neonate to Age 1)
  
  
  • Pediatric (Age 1-11)
  
  
  • Adolescent (12-18)
  
  
  • Adult (19-64)
  
  
  • Geriatric (Age 65 and older)