Utilization Review Specialist
Utilization Review Specialist
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Not Disclosed
Salary Not Disclosed
1 Vacancy
Job Description
Analyzes patient records to determine legitimacy of admission treatment and length of stay in the healthcare facility to comply with government and insurance company reimbursement policies: Analyzes insurance governmental and accrediting agency standards to determine criteria concerning admissions treatment and length of stay of patients.
Responsibilities:
- Reviews application for patient admission and approves admission or refers case to facility utilization review committee for review and course of action when case fails to meet admission standards.
- Compares inpatient medical records to established criteria and confers with medical and nursing personnel and other professional staff to determine legitimacy of treatment and length of stay.
- Abstracts data from records and maintains statistics.
- Determines patient review dates according to established diagnostic criteria.
- May assist review committee in planning and holding federally mandated quality assurance reviews.
- May supervise and coordinate activities of utilization review staff.
- Research clinical records appropriate insurance regulations and history of claim to determine next step.
- Monitor day to day compliance of appeal decision time frames and collaborate with other departments to ensure timely resolution of issues or appeals.
- Review clinical and medical records for completeness and determine administrative or clinical appeal. Assign reviews to physician advisors and medical directors for those requiring medical necessity reviews.
- Coordinate first and second level appeals.
- Consults with managers on problem cases and interfaces with case managers clinical supervisors account managers and other personnel in resolving denial and appeal questions.
- Ensure proper documentation of all denials into billing systems to include tracking outcome for reporting to appropriate parties.
- Manage first level appeals to ensure timely submissions.
- Monitor volume of appeals in order to engage additional resources when needed.
- Form professional relationships with payer appeals and utilization departments.
- Enter all data related to appeals and case reviews into a database.
- Prepare and present information on appeals to applicable committees and personnel as requested.
- Demonstrate ability to draft professional letter by incorporating supporting documents policies and statutes.
Requirements:
- Current IL issued RN license
- Graduate from an accredited nursing school.
Required Experience:
Unclear Seniority
Employment Type
Full-Time
