Job Description

The RN Utilization Review Specialist RN serves as a liaison between Shriners Hospitals and external payers on issues related to intensity of service and severity of illness and denial management activities. Conducts accurate and timely initiation and completion of payer specific information and communications flow to facilitate appropriate length of stay (LOS) and payer reimbursement.

POSITION RESPONSIBILITIES:

Clinical Review 25%

* Proficient in InterQual guidelines and able to use critical thinking skills to determine how to handle cases outside predicted pathways.
* Develops a clinical review based upon information in the patient's medical record that incorporates the severity of illness, intensity of service, plan of care, and discharge plan; and documents this clinical review.
* Communicates with Care Manager and/or physician the need for additional documentation to meet criteria for intensity of service and medical necessity.
* Refers cases to designated Physician Advisor those patients not meeting severity of illness and intensity of service.
* Independently manages workload and assigns due dates in a timely manner to be sure cases are reviewed per established department workflow.
* Communicates and collaborates with members of the interdisciplinary health care team to assist in resolving utilization management or discharge planning issues associated with the individual patient's healthcare benefits and/or insurance plan.
* Maintains a working knowledge of Utilization Review changes to facilitate accurate completion of the authorization process throughout the continuum of care.
* Identifies and documents readmission classification and reason.
* Identifies, documents, and communicates avoidable days and bill holds to Care Management.

Insurance Certification/Authorization 25%

* Communicates clinical reviews to the external case reviewers as required by contract and within guidelines for patient consent and release of medical information.
* Documents authorization numbers and certified days for individual cases in the computer system.
* Collaborates with external case managers to assure flow of information required to certify continued stay by payers.
* Promptly notifies the Care Manager of any denials or additional information requested from insurance companies.
* Maintains a working knowledge of authorization changes, contract changes, etc. to facilitate accurate completion of the authorization process throughout the continuum of care.

Denials Management 25%

* Formulates appeal letters in response to payer denial of days.
* Documents and tracks denials and status in information system.
* Provides retrospective clinical reviews upon request for external case reviewers as required by contract, and within guidelines for patient consent and release of medical information.
* Provides additional clinical information (via phone and/or fax) to external case reviewer to overturn or prevent a denial.
* Notifies care managers of insurance company denials.
* Communicates and reconciles denials and appeals with Patient Financial Services.

Other 25%

* Identifies opportunities for efficiency in work process and makes suggestions to improve workflow
* Models professional styles of communication in interactions with others.
* Able to develop presentations and present relevant complex concepts to audiences as requested.
* Capable of working remotely with minimal supervision and direction from superiors.
* Appropriately seeks resources on own and uses critical thinking skills and problem solving for complex processes before bringing the issue to superiors.
* Communicates with the financial services associates to resolve financial reimbursement problems collaboratively.
* Provides resources for physicians, care managers, business office, revenue management, etc. as needed related to criteria, admission status, third party payer guidelines and other utilization review practices.
* Flexible in discussing case findings but able to follow direction and feedback consistently once directed.
* Annually completes continuing education courses and/or professional education seminars to keep abreast of changing health care landscape.

THE QUALIFIED CANDIDATE WILL HAVE EXPERIENCE IN THE FOLLOWING AREAS :

* 5 years utilization management review with Interqual and Milliman (MCG) criteria required
* 5 years hospital experience preferred
* 1 year of pediatric care experience preferred

MINIMUM EDUCATION REQUIRED/PREFERRED :

* Bachelors of Science in Nursing (BSN) required
* RN License in State of practice and ability to obtain FL RN license required
* Applicable clinical or professional certifications in relevant fields desirable. Example of acceptable certification: HCQM certification offered through the ABQAURP group (American Board of Quality Assurance and Utilization Review Physicians)

KNOWLEDGE, SKILLS, AND COMPETENCIES :

* Analytical ability to collect information from diverse sources, apply professional principles in performing various analyses and summarize the information and data in order to solve problems.
* Ability to utilize comprehensive computer and database skills to streamline work and communicate to other team members.
* Analytical ability to resolve complex problems requiring use of basic scientific, mathematical, or technical principles and in-depth, experience-based knowledge.
* Ability to be articulate in both oral and written communications.
* Ability to independently prioritize and respond to multiple simultaneous requests.
* Able to apply previous learnings to similar cases using critical thinking skills.
* Working knowledge of referral processes, claims, case management.
* Knowledge of statistics, data collection, analysis and data presentation.
* Strong communication, interpersonal and collaboration skills.
* Has the ability to organize and work within a team environment; unite resources from multiple disciplines.
* Keyboarding skills.
* Proficient skills in Microsoft programs.
* Prior electronic health/medical records (EHR/EMR) experience.
* Use of utilization review interactive software and / or manuals.
* Previous experience attending virtual meetings.

Recommended skills

Bsn

Interqual

Milliman

Utilization Management

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Job Snapshot

Employee Type

Full-Time

Location

Work From Home, GA

Job Type

Health Care

Experience

5 years

Date Posted

02/24/2021

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