Utilization Review Specialist

Job Description

A Day In The Life

The Utilization Review Specialist (RN) is responsible for ensuring appropriate utilization of healthcare services across the continuum of care. This role evaluates patient admissions, continued stays, and transitions of care to ensure compliance with regulatory requirements, payer guidelines, and evidence-based standards of practice.

Working collaboratively with physicians, case managers, nursing staff, payers, and interdisciplinary teams, the Utilization Review Specialist promotes high-quality, cost-effective patient care while supporting optimal reimbursement and organizational performance. The position requires strong clinical judgment, critical thinking, communication skills, and knowledge of utilization management principles.

KEY AREAS OF REPSONSIBILITY

Admission

• Reviews available documentation to assess all admissions for appropriate status and services according to patient condition and diagnosis.
•  Applies standard guidelines to determine appropriateness for inpatient level of care or observation services based on documented condition plan of treatment and care.
• Supports physician decision-making by coaching on appropriateness of inpatient or observation status.
• Confers with admitting physician if documentation does not support hospital level of care to offer alternatives.
• Refers cases to the Physician Advisor when documentation is inadequate to support acute level of care and remains unresolved after discussing with referring/attending physician.
• Understands and applies federal law regarding the use of Hospital Initiated Notice of Non-Coverage (HINN) and Ambulatory Benefit Notice (ABN).
• Monitors insurer compliance with contractual obligations.
• Maintains proficiency in the use of electronic review applications including CERMe and EMR and enters information correctly, consistently and timely.
• Maintains proficiency in the use of hospital information systems to access information and record data.

Continuing Stay

• Actively participate in daily huddles, patient care conferences, and hospitalist/nurses hand-off reports to maintain knowledge about the patient’s clinical status and progression of care.
• Consults with case manager and/or physician advisor as necessary to resolve progression-of-care barriers through appropriate administrative and medical channels.
• Identify potentially unnecessary services and care delivery settings and recommend alternatives when appropriate.
• Collaborates with community physicians and hospitalists to influence transition from one level of care to another.
• Notifies insurers and third party administrators of clinical review information.
• Maintains documentation on each patient to include specific criteria that support appropriate level of care and continued stay. Performs status changes as necessary
• Refers cases to the Physician Advisor when treatment plan documentation does not support acute level of care. Monitors timeliness of PA response.
• Identify and record episodes of preventable delays or avoidable days due to failure of progression-of-care processes.
• Promote physicians’ use of evidence based protocols and/or order sets to influence high quality and cost effective care.

Transition

• Collaborate with clinical team to confirm benefit eligibility for post-acute services.
• Apply Interqual/Milliman discharge screens to assess patient’s readiness for a lower level of care.
• Updates all involved parties regarding potential, threatened or actual denials due to lack of medical necessity or barriers to the progression of care.
• Participates in reviewing 30-day Readmissions as directed by program manager.
• Reviews request for direct admissions and transfers for appropriate level of care.
• Coordinates with ED Case Manager to recommend alternate placement from the ED when patients do not qualify for Outpatient Observation or Inpatient status

Program Support

• Serves as a resource person to physicians, case managers, physician offices, and billing office for coverage and compliance issues.
• Works closely with decision support personnel to review resource utilization data and trends to identify outliers who may benefit from real time coaching to improve outcomes.
• Encourage healthcare team members in collaborative problem solving regarding appropriate use of resources.
• Assists in developing and revising policies to support utilization management activities, including criteria and guidelines for appropriate use of services, clinical practice guidelines and treatment protocols.
• Recognizes and responds appropriately to risk factors.
• Keeps current on all regulatory changes that affect medical necessity or reimbursement of acute care services and shares that information with program colleagues and hospital associates at information meetings.
• May represent Utilization Management on various committees, professional organizations, physician or and community groups
• Establish and maintain effective professional working relationships with patients, families, interdisciplinary team members, payers and external case managers

Qualifications

Requirements 

• Current licensure as a Registered Nurse (RN) in the State of Michigan.
• Minimum of three years clinical experience required.
• Strong clinical assessment, critical thinking, and decision-making skills.
• Effective verbal and written communication skills.
• Proficiency in Microsoft Office, Outlook, and related computer applications.
• Ability to independently organize workload, manage competing priorities, and meet deadlines.
• Demonstrated attention to detail and problem-solving abilities.

Preferred

• Previous utilization review, utilization management, or case management experience within a hospital or insurance setting.
• Knowledge of managed care, Medicare, Medicaid, HMOs, and reimbursement methodologies.
• Experience with discharge planning and transitions of care.
• EHR Cerner exprience. 

Additional Information

Schedule:

Typically M-F 2PM -10:30PM with a weekend rotation every 4/5 weekend. Rotating holiday work as needed. 

Locations:

MMC ED and Copper Ridge. 

Once established this position will be 50/50 hybrid & onsite.

Training Schedule: 

Onsite M-F 8AM -4:30PM for the first 8 weeks (estimated).

Munson Healthcare requires all employees be vaccinated or have lab confirmed immunity for Measles, Mumps, Rubella and Varicella. MHC also requires all employees to receive a flu vaccine during the flu season in the year that they are hired and annually thereafter, or receive an approved medical or religious exemption.