Utilization Review Specialist (RN)Sturdy Health • Attleboro, Massachusetts, United States
Utilization Review Specialist (RN)
Sturdy Health
- Attleboro, Massachusetts, United States
- Attleboro, Massachusetts, United States
Über
Must be able to facilitate correct identification of patient status (inpatient, observation status) so that appropriate claim can be submitted to commercial and government payers Complete short stay reviews (one midnight); track and trend results for reporting and education purposes. Identify opportunities for process and system improvement and initiate and support performance improvement as indicated Collaborate with nursing, physicians, admissions, fiscal, legal, compliance, coding, and billing staff to answer clinical questions related to medical necessity and patient status Facilitate annual update of InterQual software (collaborating with Information Systems staff), assist in creation of training tools, and provide training as needed to RN CMs Knowledge in areas of: Medicare and Medicaid UM regulations, InterQual, Medicare Inpatient Only List, RAC, QIO, MAC, and Denial Management Develop review process for OR and ED patients at portals of entry Minimum 3-5 years acute care case management experience, with demonstrated skills in utilization review Excellent computer skills: Adept at utilizing Excel and other software programs to prepare and present data and trend charts at Utilization Review Committee Meetings Demonstrated ability to use critical thinking and problem solving skills in facilitating safe and timely patient transitions of care Excellent communication skills and positive interpersonal dynamic in working with a variety of stakeholders across the care continuum, including physicians Solid knowledge of all insurance plan regulations including CMS/Medicaid to ensure compliance with all required processes and documentation, while minimizing denials Strong analytical ability to interpret patient-related information, evaluate appropriateness of continued stay and/or need for ancillary services, and to reassess discharge planning needs based on daily assessment. Ability to successfully utilize industry accepted utilization and or medical management criteria in patient status decision making Self-starter able to function independently within the scope of position and licensure, as well as department policies and established goals
Preferred Skills/Qualifications/Training/Experience:
Experience in Cerner a plus Experience in Denials management, maintaining software based tracking of appeal status Strength in data analytics to aggregate and monitor utilization data, reporting out on trends and key metrics Strong knowledge of revenue cycle activities and CM related impact on same
Educational Requirements:
BSN Graduate of an accredited school of nursing with advanced degree preferred
License/Certification:
RN with current Massachusetts license required CCM (Certified Case Manager) and/or ACMA (Accredited Case Manager) Board Certification in Nursing Case Management (RN-BC) through ANCC (American Nurses Credentialing Center)
Salary Range Details The pay range displayed on each job posting reflects the anticipated range for new hires. A successful candidate's actual compensation will be determined after taking factors into consideration such as the candidate's work history, experience, skill set, and education. This is not inclusive of the value Sturdy Health's benefits package (if applicable), which includes among other benefits, healthcare/dental/vision and retirement. For annual salaries this is based on full-time employment. Sturdy Memorial Hospital is an equal employment opportunity employer. There is no discrimination because of race, color, creed, age, gender, sexual orientation, national origin, veteran status or disability.
Sprachkenntnisse
- English
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