What are the responsibilities and job description for the Clinical Utilization Review Specialist position at Core Management Resources Group?
Job Summary
The Utilization Review Nurse plays a critical role in evaluating the appropriateness of patient care and ensuring that healthcare services are delivered effectively and efficiently. This position involves reviewing medical records, collaborating with healthcare providers, and applying clinical knowledge to assess the necessity of services provided to patients. The ideal candidate will possess a strong understanding of utilization management principles.
Duties
- Conduct thorough reviews of medical records to evaluate the necessity and appropriateness of patient care.
- Collaborate with healthcare teams to ensure compliance with clinical guidelines and standards.
- Perform diagnostic evaluations to determine the level of care required for patients.
- Ensure adherence to HIPAA regulations while handling sensitive patient information.
- Utilize knowledge from working in Level I and Level II Trauma Centers to inform decision-making processes.
- Provide recommendations for care based on evidence-based practices and utilization management protocols.
- Document findings and communicate effectively with healthcare providers regarding patient status and care plans.
- Participate in quality improvement initiatives related to utilization review processes.
Qualifications
- Registered Nurse (RN) or LPN license required; additional certifications in utilization management preferred.
- Familiarity with social work principles and their application in healthcare settings is a plus.
- Strong understanding of diagnostic evaluation processes and medical record documentation.
- Knowledge of HIPAA regulations and commitment to maintaining patient confidentiality.
- Previous experience in utilization management or similar roles is advantageous.
- Excellent communication skills, both verbal and written, with the ability to collaborate effectively with multidisciplinary teams.
- Strong analytical skills with attention to detail for accurate assessment of patient needs.
This position offers an opportunity for nurses looking to expand their expertise in utilization review while contributing positively to patient outcomes within a dynamic healthcare environment. LPN or RN accreditation is required. Position may offer flex/part-time option with the ideal candidate.
Job Types: Full-time, Part-time
Pay: $35.00 - $42.00 per hour
Benefits:
- 401(k)
- Dental insurance
- Health insurance
- Life insurance
- Paid time off
Schedule:
- 4 hour shift
- 8 hour shift
- Monday to Friday
Work Location: In person
Salary : $35 - $42