RN Utlization Review Specialist

3 weeks ago

New York, United States American Consultants Full time
Job DescriptionJob Description

RN Utilization Review Specialist- New York

American Consultants is looking for an perm Utilization Review Specialist for a facility in NY. Must have New York RN license

Position Summary: Under the direct supervision of the HIM manager, the UR specialist monitors the utilization of resources, risk management and quality of care for patients in accordance to established guidelines and criteria for designated setting and status. Collection of clinical information necessary to initiate commercial payer authorization. Obtain and maintain appropriate documentation concerning services in accordance to reimbursement agency guidelines.

Excellence in Practice
Performs preadmission review on admissions when required by insurance companies/agencies to comply with policies and procedures. Works in coordination with discharge planner, monitoring medical necessity for admissions, and appropriate level of services. May also need to notify physician and patient of authorization denials.
Inputs collected data into computer system for insurance communication.
Assists with retrospective review of specified charts as required Obtains extensions in length of stays from insurance companies if needed. Obtains preauthorization and/or precertification of services.
Reviews hospital records daily to determine if utilization resources could be served in a better environment, OBS vs INPT.
Ability to interact on an interpersonal basis with providers and other staff within the organization. Innovation in Service · Serves as a role model for the organization and exemplifies the corporate values of WRHSF. · Attends all required training sessions provided by the facility and others as required for licensing. · Demonstrates understanding of emergency procedures (example, fire drills, bomb threats, tornado, disaster plans and other procedures) · Cooperates when implementing changes that affect the organization. Compassion for the people we serve · Demonstrates courtesy, cooperation and sensitivity toward patients, family and visitors. · Displays empathy and offers support for employees, patients and visitors throughout the facility. · Maintains a warm and welcoming environment for all individuals and demonstrates caring and concern.
Respect for one another · Maintains strict confidentiality of patient and organizational information. · Adheres to all Administrative and Personnel Policies (example: dress code policy, attendance policy, parking policy and all others)
· Promotes positive relationships within your own department · Promotes positive relationships with other departments within the organization

Essential Job Requirements:

Education: Appropriate education level required in according with licensure.

Experience: Three years of relevant experience with superior communication and interpersonal skills. Minimum one year healthcare or clinical experience required.

License Requirements: Registered Nurse license with State Nursing Board. Additional coding certifications also acceptable such as certified coding specialist (CCS), certified coding specialist physician (CCS-P), certified professional coder (CPC), and certified professional coder – hospital (CPC-H).

#THP

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