What are the responsibilities and job description for the Utilization Review Specialist position at Ephraim McDowell Health?
Job Description
JOB SUMMARY:
Under the general direction of the director, provides utilization review for appropriateness of admission and continued stay per guideline according to established criteria. This position will review patient medical records, clinical documentation, and treatment plans to ensure that services align with payer criteria, evidence-based guidelines, and regulatory requirements. The UR Specialist collaborates with physicians, case management, coding, and billing teams to ensure accurate and timely reimbursement for services rendered while minimizing claim denials. Exhibits the F.I.R.S.T. values (Friendliness, Innovation, Respect, Service, and Trust).
WORKING CONDITIONS, HAZARDS AND PHYSICAL EFFORT:
Works in a typical office environment. and moves throughout the Medical Center. Moderate amount of walking required. Moderate amount of stress in working with physicians. The task of this job does not involve exposure to blood, body fluids, or tissue. Must be able to move or position 25 lbs. independently.
CONTACTS WITH OTHERS:
Nursing staff, Nursing staff, physicians, physicians office staff, department directors, ancillary staff, patients, families, review specialist, other Case Management Associates, Insurance Companies.
EQUIPMENT USED/SPECIAL SKILLS REQUIRED:
Proficient computer skills required. Preferred knowledge of the Meditech software
or equivalent. Must be skilled in interpretation of Medicare/Medicaid regulations and third party payers regarding Medical Center services including discharge planning. Must be skilled in medical terminology and diagnosis. Utilizes communication skills with a high degree of effectiveness in working with patients, families, physicians, Medical Center Associates and review agencies.
MINIMUM QUALIFICATIONS OR EQUIVALENTS:
Education: Graduate of an approved school of nursing, Certified Nursing
Assistant (CNA), Certified Medical Assistant (CMA,) or medical record technology
or equivalent.
Experience: Five (5) years experience in an acute care setting; Previous
experience in this utilization review preferred.
Licenses, Certifications and/or Registrations:
LPN, CNA, or CMA preferred.
Position Type
Full Time
