Clinical Utilization Review Specialist

4 weeks ago


Springfield, Massachusetts, United States Trinity Health Full time
Job Description

At Trinity Health, we are seeking a skilled Clinical Utilization Review Specialist to join our team. As a Utilization Review and Appeals RN, you will play a critical role in ensuring that our patients receive the highest quality care while also promoting efficient use of healthcare resources.

  • Perform thorough utilization reviews to determine the medical necessity of patient care services.
  • Collaborate with physicians and other healthcare professionals to develop and implement effective care plans.
  • Educate patients and their families about their financial responsibilities and provide guidance on navigating the healthcare system.
  • Identify and address barriers to effective patient care management, promoting improvements in work processes and patient outcomes.
  • Refer quality issues and poor utilization of services to the appropriate sources for review and resolution.
  • Provide consultation to professional staff and physicians on level of care determinations, CMS regulations, and payer-specific guidelines.
  • Document clinical reviews in accordance with documentation standards, policies, procedures, and/or guidelines.

Requirements:

  • Education: Graduate of an accredited college or university affiliated nursing program. BSN graduate preferred, Master's preferred.
  • Licensure: Current licensure as a Registered Nurse RN in Massachusetts.
  • Certification: BLS (AHA/ARC). CCM or ACM Certification preferred.

Preferred Skills:

  • 3-5 years in similar experience preferred, hospital or community-based. Knowledge of budget processes, quality improvement, report distribution, TJC standards, state and federal regulations, six sigma, and LEAN methodologies.

Work Schedule:

  • PER DIEM Option A, 4 Shifts a month.


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