UTILIZATION REVIEW

Job Description

POSITION POSTING: Utilization Review DEPARTMENTS: Nursing STATUS Part-Time: 24 hours per week

HOURS: Day shift. Hours may be adjusted in response to workload demands; Low census may be utilized in accordance

with hospital policy.

JOB SUMMARY:

Under the direction of the Director of the Nursing Services and with limited supervision and broad general direction, performs Utilization Review according to hospital policy and procedures. Promotes, coordinates and takes responsibility for completion of all activities associated with utilization review: Applies approved utilization criteria to assess appropriateness of admissions, levels of care, and continued stays. Communicates with third-party payors for initial and concurrent clinical reviews and collaborates with physicians/providers when patients no longer meet medical necessity criteria. Educates and partners with staff on utilization processes, regulations, and documentation requirements to ensure accurate classification of stay types and durations. Tracks length of stay (LOS) and resource utilization to identify at risk patients. The Utilization Reviewer will work with the manager or designee of the Billing Department to complete outpatient authorizations as assigned, verify insurance coverage, and covered services.

QUALIFICATIONS/POSITION REQUIREMENTS:

A. Education/Experience

Associates degree in nursing, social work, related field, or equivalent experience, required. Bachelors preferred.

Certification in Utilization Review/Utilization Management, preferred.

Two years previous experience in Utilization Review, Authorization, and/or Case Management, required.

Experience in healthcare privacy/security/HIPAA.

Excellent verbal and written communication skills; ability to speak clearly and concisely, conveying complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others.

Advanced interpersonal (e.g., mediating, counseling, mentoring, influencing), negotiating and management skills required to manage critical internal and external relationships and activities.

Ability to collaborate constructively with others within and outside the organization.

High level of integrity as demonstrated by appropriate treatment of confidential information, adherence to policies, procedures, rules and regulations, professional conduct in dealing with internal and external individuals.

Demonstrated knowledge of payors, payor systems, cost effective utilization management, insurance terminology, InterQual criteria and Milliman guidelines, preferred.

B. Personal Skills

Demonstrates ability to establish effective working relationships and effective communication with peers, patients, families, physicians, and all other hospital support personnel.

Knowledge of Federal and State programs, and Third-party payor utilization review programs and requirements.

Ability to apply InterQual and other applicable criteria for all applicable inpatients and outpatients on a concurrent basis.

Ability to utilize appeals management skills and plans to work with third-party payors to meet payor requirements.

Exhibits strong reading and writing skills, communication skills, and leadership skills.

Supports and contributes to the total hospital system by:

Maintaining a hospital-wide perspective

Serving on department/hospital committees

Influences the direction of Nursing services by maintaining a positive perspective/attitude.

Demonstrates the ability to handle multiple tasks in a stressful situation while maintaining composure and excellence in the delivery of Utilization Management services.

Knowledge and Demonstration of computerized health record and medical terminology.

Equal Opportunity Provider and Employer: McKenzie Health System is an equal opportunity provider and employer. All qualified applicants receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status. If you are unable to complete this application due to a disability, contact this employer to ask for an accommodation or an alternative application

If you are unable to complete this application due to a disability, contact this employer to ask for an accommodation or an alternative application process.

Part-time