What are the responsibilities and job description for the Specialist , Utilization Review position at Oaklawn Hospital?
Job Summary: Reviews and screens the appropriateness of services, the utilization of hospital resources and the quality of patient care rendered.
Essential Functions:
- Consistently uses an outward mindset and puts forth exemplary effort in accomplishing his/her goals and objectives in a manner that helps others to achieve their goals and objectives.
- Conducts concurrent or extended stay reviews on appropriate day and/or specified time
- Combines clinical, business and regulatory knowledge and skill to reduce significant financial risk and exposure caused by concurrent and retrospective denial of payments for services provided
- Prepares and submits appeals to payors, effectively coordinating collection of all pertinent data to support the hospital and patient’s position
- Maintains and updates reviews in the electronic medical record (EMR) and maintains other appropriate records as needed
- Communicates pertinent payor issues to physician and other caregivers
- Understands and communicates insurance information to team members, including benefits and levels of care
- Prepares any reports assigned or requested by the Manager of Case Management or his/her supervisor
Minimum Qualifications: Licensed in the State of Michigan as a Registered Nurse. Three (3) years of clinical experience.
Knowledge, Skills & Abilities: Bachelor’s degree preferred. Previous utilization management or case management experience preferred. Demonstrated competence with basic Microsoft Office tools. Knowledge of outside regulatory agencies inter-face with the institution. The ability to communicate with individuals from various backgrounds regarding a variety of hospital-wide practices. Strong critical thinking skills necessary to assess documentation of care provided in EMR. Excellent prioritization and organizational skills emphasized.
Working Conditions/Physical Requirements: Work is generally sedentary in nature, but may require standing and walking for up to 10% of the time. Work is generally performed within an office environment, with standard office equipment available.
