UR Specialist

2 weeks ago

Statesboro GA United States Willingway Full time
UR Specialist - RN/LPN | Willingway | Statesboro, GeorgiaAbout the Job:
The Utilization Specialist is responsible for reviewing of assigned admissions, continued stays, utilization practices and discharge planning according to approved clinically valid criteria which meets the daily deadlines to obtain authorizations and complete other pertinent processes. Coordinates, performs, and monitors all utilization review/management activities of the hospital to continuously improve the collection, reimbursement, coordination, and presentation of utilization review information; Educates hospital staff about requirements and trends.
Roles and Responsibilities:

* Performs admission, concurrent, continued stay, and retrospective reviews using the established hospital criteria. Communicates effectively with insurance companies, health maintenance organization (HMOs) and other similar entities for approval of initial or additional days for treatment. Provides information they

need in a logical, concise manner using technical language that accurately describes client’s condition and need for hospitalization.

* Communicates directly with physicians and other providers with respect to specific inquires and perceived trends of issues as they relate to utilization management.
* Appeals all denials ensuring accuracy of information and effective coordination of correspondence. Initiates, coordinates, and monitors the appeal process. Provides information to physicians to assist them in their role in appeals.
* Assists the admissions department with pre-certifications of care. Performs pre and post admission benefit verification with managed care organizations.
* Maintains accurate documentation and files as it relates to utilization management.
* Provides ongoing support and training for staff on documentation or charting requirements, continued stay criteria and medical necessity updates.
* Communicates effectively with co-workers, program, and nursing staff regarding charting deficiencies and problems/issues identified. Follows up in each instance to determine if corrective action was taken. Notifies supervisor if corrective action is not completed.
* Coordinates information and findings with the business office to help recognize or resolve possible payment problems.
* Monitors client length of stay and extensions and informs clinical and medical staff on issues that may impact length of stay. Investigates short term length of stays and endeavor to create alternate financial planning which would offer the client extended days of treatment. Participates in discharge planning as required.
* Gathers and develops statistical and narrative information to report on utilization, non-certified days (including identified causes and appeal information), discharges and quality of services, as required by the facility leadership or corporate office.
* Conducts quality reviews for medical necessity and services provided. Facilitates peer review calls between facility and external organizations. Identifies potential review problems and discuss them with multi-disciplinary team and/or administration.
* Acts as liaison between managed care organizations and the facility professional clinical staff.
* Assists with any problems encountered during on-site or telephone reviews by the third-party payers or review organization, when necessary.
* Graduation from an approved/accredited school of nursing or a bachelor's degree in social work, behavioral or mental health, or other related health field preferred.
* One or more years of direct clinical experience in a substance abuse setting and ASAM experience preferred.

Why Willingway?Willingway offers a comprehensive benefit plan and a competitive salary commensurate with experience and qualifications. Qualified candidates should apply by submitting a resume. Willingway is an EOE.
Veterans and military spouses are highly encouraged to apply. Summit BHC is dedicated to serving Veterans with specialized programming at our treatment centers across the country. We recognize and value the unique strengths of the military community in supporting our mission to serve those who have served.

Job Type: Full-time

  • UR Specialist

    1 week ago

    Statesboro, GA, United States Willingway Full time

    UR Specialist - RN/LPN | Willingway | Statesboro, GeorgiaAbout the Job: The Utilization Specialist is responsible for reviewing of assigned admissions, continued stays, utilization practices and discharge planning according to approved clinically valid criteria which meets the daily deadlines to obtain authorizations and complete other pertinent processes....

  • UR Specialist

    2 weeks ago

    Statesboro, United States Willingway Full time

    UR Specialist - RN/LPN | Willingway | Statesboro, GeorgiaAbout the Job:The Utilization Specialist is responsible for reviewing of assigned admissions, continued stays, utilization practices and discharge planning according to approved clinically valid criteria which meets the daily deadlines to obtain authorizations and complete other pertinent processes....

  • UR Specialist

    1 week ago

    Statesboro, GA, US Willingway Full time

    UR Specialist - RN/LPN | Willingway | Statesboro, GeorgiaAbout the Job:The Utilization Specialist is responsible for reviewing of assigned admissions, continued stays, utilization practices and discharge planning according to approved clinically valid criteria which meets the daily deadlines to obtain authorizations and complete other pertinent processes....

  • UR Specialist

    1 week ago

    Statesboro, United States Summit BHC Full time

    UR Specialist - RN/LPN | Willingway | Statesboro, GeorgiaAbout the Job:The Utilization Specialist is responsible for reviewing of assigned admissions, continued stays, utilization practices and discharge planning according to approved clinically valid criteria which meets the daily deadlines to obtain authorizations and complete other pertinent processes....

  • UR Specialist

    1 week ago

    Statesboro, GA, United States Willingway Full time

    The Utilization Specialist is responsible for reviewing of assigned admissions, continued stays, utilization practices and discharge planning according to approved clinically valid criteria which meets the daily deadlines to obtain authorizations and complete other pertinent processes. Coordinates, performs, and monitors all utilization review/management...

  • Registered Nurse

    3 days ago

    Spring Hill, FL, United States The Tampa General Hospital Full time

    Registered Nurse* Initial clinical assessments, continued stays 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...

  • Registered Nurse

    1 month ago

    Spring Hill, FL, United States The Tampa General Hospital Full time

    Registered NurseTGH Brooksville & Spring Hill are a 244-bed Health System Joint Commission, Accredited Chest Pain Center, and Primary Stroke Center. TGH Brooksville care services include a surgery program, a dedicated orthopedic joint replacement center and two cardiac catheterization labs. The joint replacement program offers robotic-arm assisted partial...

  • Primary Care Network

    2 weeks ago

    Rochester, NY, United States University of Rochester Full time

    Responsibilities PT or FT position available. Monday - Friday, daytime hours. Exciting opportunity for an experienced NP or PA to join a busy Family Medicine practice and become part of an interdisciplinary team that provides patient care utilizing the Patient Centered Medical Home model. This is a fast-paced rural office located in Perry, NY. The...

  • CDI Specialist III Registered Nurse

    1 month ago

    Orlando, FL, United States Orlando Health Full time

    CDI Specialist III Registered Nurse - Clinical Documentation - Orlando HealthPosition Summary Provides concurrent review of the clinical documentation in the medical record; review the medical record with a clinical lens to identify any missing or understated diagnoses or procedures. This is a hybrid role Responsibilities Conducts initial and follow-up...

  • Utilization Review Coordinator

    2 weeks ago

    Bakersfield, CA, United States Bakersfield Behavioral Healthcare Hospital Full time

    About UsBakersfield Behavioral Healthcare Hospital, located in Bakersfield, California, is an acute psychiatric and behavioral 90 bed facility situated on 8.8 acres.We offer inpatient and outpatient services for children, adolescents and adults needing mental/behavioral health, chemical dependency; and co-occurring disorders treatment through our medically...

  • CDI Specialist I Registered Nurse

    3 weeks ago

    Orlando, FL, United States Orlando Health Full time

    CDI Specialist I Registered Nurse - Clinical Documentation - Arnold Palmer HospitalPosition Summary Provides concurrent review of the clinical documentation in the medical record; review the medical record with a clinical lens to identify any missing or understated diagnoses or procedures. This is a hybrid position, hospital will be Arnold Palmer Childrens...

  • CDI Specialist I Registered Nurse

    1 month ago

    Orlando, FL, United States Orlando Health Full time

    CDI Specialist I Registered Nurse - Clinical Documentation - Arnold Palmer HospitalPosition Summary Provides concurrent review of the clinical documentation in the medical record; review the medical record with a clinical lens to identify any missing or understated diagnoses or procedures. This is a hybrid position, hospital will be Arnold Palmer Childrens...

  • Primary Care Network

    2 weeks ago

    Rochester, NY, United States University of Rochester Full time

    Responsibilities Exciting opportunity to join a busy Family Medicine medical practice in the Hornell & Bath, NY area and become part of an interdisciplinary team that provides patient care utilizing the Patient Centered Medical Home model. Responsibilities include: evaluation and management of acute/chronic illnesses, ordering/interpreting/communicating...

  • Primary Care Network

    2 weeks ago

    Rochester, NY, United States University of Rochester Full time

    Responsibilities Exciting opportunity for an experienced NP or PA to join a busy Family Medicine/Med-Peds practice and become part of an interdisciplinary team that provides patient care utilizing the Patient Centered Medical Home model. This is a fast-paced office in the Bushnell's Basin, NY area. The providers care for newborns, children, teenagers, and...

  • RN Case Manager 32HRW

    4 days ago

    Houston, TX, United States Erickson Living Full time

    RN Case Manager 32HRWLocation: Eagle's Trace by Erickson Senior Living Eagle's Trace is a beautiful 70-acre continuing care retirement community located just minutes from the metroplex in West Houston, Texas. We're part of a growing network of communities developed and managed by Erickson Senior Living, a national provider of senior living and health care...

  • RN Case Manager

    3 weeks ago

    Weymouth, MA, United States South Shore Health Full time

    Job Description SummaryThe Case Manager provides clinically based case management, discharge planning and care coordination to facilitate the delivery of cost-effective quality healthcare and assists in the identification of appropriate utilization of resources across the continuum of care. Works collaboratively with interdisciplinary staff internal and...