Utilization Review Clinical Specialist
2 weeks ago
Job Description
Community Health Systems is one of the nation's leading healthcare providers. Developing and operating healthcare delivery systems in 41 distinct markets across 15 states, CHS is committed to helping people get well and live healthier. CHS operates 74 acute-care hospitals and more than 1,000 other sites of care, including physician practices, urgent care centers, freestanding emergency departments, occupational medicine clinics, imaging centers, cancer centers and ambulatory surgery centers.
Summary:
Utilization management is the analysis of the necessity, appropriateness, and efficiency of medical services and procedures in the hospital setting. Utilization review is the assessment for medical necessity, both for admission to the hospital as well as continued stay. This function ensures that services are not only appropriate, but ensures that an authorization for services is obtained from payer, if required, and that documentation supports the care delivered in such a way that minimizes the risk of denials after discharge.
Essential Duties:
* Initial clinical assessments, continued stay assessments, and payer requested reviews are performed using evidence based criteria as designed, medical experience based problem solving skills, and following the established policies and regulations governing this process in order to either obtain authorization or establish medical necessity for hospitalized patients.
* Hold collaborative discussions with physicians on the medical staff, when needed, to obtain additional documentation in the record to support hospital medical necessity, discharge needs, or fulfill other payer requirements. These discussions are to help the UR Clinical Specialist understand the reason for admission, and better be able to request appropriate additional documentation from the physician(s).
* Escalates cases to the Utilization Review Manager and/or Physician Advisor if physicians are unable to provide any additional information to support the need for medically necessary hospital care.
* Documents all actions and activities in the case management software system used by the hospital. This documentation includes, but is not limited to, clinical reviews, escalations, avoidable days, payer contacts, authorization numbers, wDRG etc. Documentation may also be made in other systems as required based on hospital and/or corporate policies/procedures.
* In the event of concurrent denials, the UR Clinical Specialist reviews the denial and works with the physicians on the medical staff hospital's to perform an internal secondary review to determine if there is need to downgrade the visit. The UR Clinical Specialist may assist coordinating a Peer to Peer discussion according to hospital and/or corporate direction. Results of the Peer to Peer are to be gathered from the physician presenting after the call and documented in the case management system by the UR Review Specialist.
* In the event a facility does not have an ED Case Manager present, the UR Clinical Specialist will collaborate with Emergency Room Physician/staff on ALL potential admissions during assigned hours to:
* Determine, if the patient is going to be admitted, and ensure appropriate documentation to validate the admission as an inpatient or to place in outpatient with observation services.
* Review medical record for appropriate indicators of the medical necessity for hospital care, and work with the healthcare team to ensure that medical necessity is clearly documented within the medical record.
* Educate physicians/healthcare team regarding appropriate documentation to support level of care using approved evidence based criteria as a guide.
* Document in the appropriate case management EMR the medical necessity information supporting the admission.
* UR Clinical Specialist communicates with the UR Coordinator and facility case manager(s) (i.e. licensed social workers,discharge planners, etc.) in -person, telephonically, and/or through the case management software to ensure effective collaboration between all disciplines managing a patient's care.
Qualifications:
* Required Education: Associates Degree in Nursing
Preferred Education: Bachelors Science Nursing or higher
* Required Experience: At least 3 years previous nursing experience
Preferred Experience: 3 plus years Utilization review experience
* Required License/Registration/Certification: Licensed Practical Nurse or Licensed Registered Nurse
Preferred License/Registration/Certification: ACM or CCM Certification
* Computer Skills Required: Data entry skills; Demonstrable skills with Google Docs, Google Sheets, and email applications.
Physical Demands:
In order to successfully perform this job, with or without a reasonable accommodation, the following are outlined below:
1. The Employee is required to read, review, prepare and analyze written data and figures, using a PC or similar, and should possess visual acuity.
2. The Employee may be require to occasionally climb, push, stand, walk, reach, grasp, kneel, stoop, and/or perform repetitive motions.
3. The Employee is not substantially exposed to adverse environmental conditions and; therefore, job functions are typically performed under conditions such as those found within general office or administrative work. May be exposed to biohazardous material and pathogens.
-
Utilization Review Clinical Specialist
3 weeks ago
Franklin, United States Community Health System Full timeJob Description Community Health Systems is one of the nation's leading healthcare providers. Developing and operating healthcare delivery systems in 41 distinct markets across 15 states, CHS is committed to helping people get well and live healthier. CHS operates 74 acute-care hospitals and more than 1,000 other sites of care, including physician...
-
Utilization Review Clinical Specialist
3 weeks ago
Franklin, United States Community Health System Full timeJob Description Community Health Systems is one of the nation's leading healthcare providers. Developing and operating healthcare delivery systems in 41 distinct markets across 15 states, CHS is committed to helping people get well and live healthier. CHS operates 74 acute-care hospitals and more than 1,000 other sites of care, including physician...
-
Utilization Review Clinical Specialist
1 week ago
Franklin, United States Community Health System Full timeJob Description Community Health Systems is one of the nation's leading healthcare providers. Developing and operating healthcare delivery systems in 41 distinct markets across 15 states, CHS is committed to helping people get well and live healthier. CHS operates 74 acute-care hospitals and more than 1,000 other sites of care, including physician...
-
ClinicalUtilization Review Nurse
2 weeks ago
Franklin, United States Aspirion Health Resources Full timeWhat is Aspirion? For over two decades, Aspirion has delivered market-leading revenue cycle services. We specialize in collecting challenging payments from third-party payers, focusing on complex denials, aged accounts receivables, motor vehicle accident, workers’ compensation, Veterans Affairs, and out-of-state Medicaid. At the core of our success is our...
-
Clinical Lab Specialist
1 month ago
Franklin Lakes, United States MILLENNIUMSOFT Full timeHello There, We at Millenniumsoft looking for Clinical Lab Specialist & Clinical Lab Assistant /Sample Processor with5 years’+ experience in clinical laboratory science or in clinical research, product investigations, troubleshooting abnormal laboratory results and product development with clinical trials’ experience desired. Job Title – Clinical...
-
Clinical Laboratory Specialist
4 weeks ago
Franklin Lakes, United States Amerit Consulting Full timePosition: Clinical Lab SpecialistLocation: Franklin Lakes, NJ 07417Duration: 12 Months contract with possible extensionPay Rate: $40/hr - $47/hr (depending on experience)Job Description:On Site in Flks 5 days WEEK 8:30 TO 5:00Working with Human BloodShould either have ASCP generalist certification OR eligible to receive one.This laboratory-based position...
-
Clinical Laboratory Specialist
4 weeks ago
Franklin Lakes, United States Amerit Consulting Full timePosition: Clinical Lab SpecialistLocation: Franklin Lakes, NJ 07417Duration: 12 Months contract with possible extensionPay Rate: $40/hr - $47/hr (depending on experience)Job Description:On Site in Flks 5 days WEEK 8:30 TO 5:00Working with Human BloodShould either have ASCP generalist certification OR eligible to receive one.This laboratory-based position...
-
Clinical Laboratory Specialist
4 weeks ago
Franklin Lakes, United States Amerit Consulting Full timePosition: Clinical Lab SpecialistLocation: Franklin Lakes, NJ 07417Duration: 12 Months contract with possible extensionPay Rate: $40/hr - $47/hr (depending on experience)Job Description:On Site in Flks 5 days WEEK 8:30 TO 5:00Working with Human BloodShould either have ASCP generalist certification OR eligible to receive one.This laboratory-based position...
-
Clinical Laboratory Specialist
4 weeks ago
Franklin Lakes, United States Amerit Consulting Full timePosition: Clinical Lab SpecialistLocation: Franklin Lakes, NJ 07417Duration: 12 Months contract with possible extensionPay Rate: $40/hr - $47/hr (depending on experience)Job Description:On Site in Flks 5 days WEEK 8:30 TO 5:00Working with Human BloodShould either have ASCP generalist certification OR eligible to receive one.This laboratory-based position...
-
Clinical Laboratory Specialist
2 weeks ago
Franklin Lakes, United States Amerit Consulting Full timePosition: Clinical Lab SpecialistLocation: Franklin Lakes, NJ 07417Duration: 12 Months contract with possible extensionPay Rate: $40/hr - $47/hr (depending on experience)Job Description:On Site in Flks 5 days WEEK 8:30 TO 5:00Working with Human BloodShould either have ASCP generalist certification OR eligible to receive one.This laboratory-based position...
-
Clinical Laboratory Specialist
2 weeks ago
Franklin Lakes, United States Amerit Consulting Full timePosition: Clinical Lab SpecialistLocation: Franklin Lakes, NJ 07417Duration: 12 Months contract with possible extensionPay Rate: $40/hr - $47/hr (depending on experience)Job Description:On Site in Flks 5 days WEEK 8:30 TO 5:00Working with Human BloodShould either have ASCP generalist certification OR eligible to receive one.This laboratory-based position...
-
Revenue Cycle Specialist
2 weeks ago
Franklin, United States Acadia Healthcare Full timeOverview: Now Hiring : Revenue Cycle Specialist Franklin, TN Our Team: We are improving the lives we touch. We need passionate, talented people working together who share our desire to create a world-class organization that sets the standard of excellence in the treatment of speciality behavioral health and addiction disorders.Acadia Healthcare is...
-
Revenue Cycle Specialist
2 weeks ago
Franklin, United States Acadia Healthcare Full timeOverview: Now Hiring : Revenue Cycle Specialist Franklin, TN Our Team: We are improving the lives we touch. We need passionate, talented people working together who share our desire to create a world-class organization that sets the standard of excellence in the treatment of speciality behavioral health and addiction disorders.Acadia Healthcare is...
-
Clinical Care Manager
16 hours ago
Franklin, United States UPMC Full timeAre you looking for an opportunity to use your nursing background in outpatient, home health, or case management? Do you have an interest in health insurance, but thrive on working in a medical office setting with face-to-face interaction with the members you are caring for? UPMC Health Plan is hiring a full-time Clinical Care Manager to support our...
-
Clinical Care Manager
1 day ago
Franklin, United States University of Pittsburgh Medical Center Full timeAre you looking for an opportunity to use your nursing background in outpatient, home health, or case management? Do you have an interest in health insurance, but thrive on working in a medical office setting with face-to-face interaction with the members you are caring for? UPMC Health Plan is hiring a full-time Clinical Care Manager to support our...
-
Clinical Care Manager
5 days ago
Franklin, United States UPMC - Pittsburgh Medical Center Full timeJob DescriptionAre you looking for an opportunity to use your nursing background in outpatient, home health, or case management? Do you have an interest in health insurance, but thrive on working in a medical office setting with face-to-face interaction with the members you are caring for? UPMC Health Plan is hiring a full-time Clinical Care Manager to...
-
Patient Service Specialist
5 days ago
Franklin, United States Vanderbilt Health Full timeDiscover Vanderbilt University Medical Center: Located in Nashville, Tennessee, and operating at a global crossroads of teaching, discovery, and patient care, VUMC is a community of diverse individuals who come to work each day with the simple aim of changing the world. It is a place where your expertise will be valued, your knowledge expanded, and your...
-
Franklin, United States Community Health System Full timeJob Description Summary: Community Health Systems, CHSPSC, LLC is seeking a Senior, Medication Management Applications Specialist for its Franklin, TN headquarters' Clinical Informatics team. This senior-level position with the Clinical Informatics team is responsible for strategy and execution of clinical decision support tools, integrated workflow...
-
Franklin, United States Community Health System Full timeJob Description Summary: Community Health Systems, CHSPSC, LLC is seeking a Senior, Medication Management Applications Specialist for its Franklin, TN headquarters' Clinical Informatics team. This senior-level position with the Clinical Informatics team is responsible for strategy and execution of clinical decision support tools, integrated workflow...
-
Home Health RN Clinical Manager
3 weeks ago
Franklin, United States TriStar Healthcare at Home Full timeDescription Sign On Bonus $5000IntroductionAre you looking for a place to deliver excellent care patients deserve? At TriStar Healthcare at Home we support our colleagues in their positions. Join our Team as a(an) Home Health RN Clinical Manager and access programs to assist with every stage of your career.BenefitsTriStar Healthcare at Home, offers a total...
