RN Utilization Review Specialist
2 weeks ago
At Baptist Memorial Healthcare Corporation, we are seeking a skilled RN Utilization Review Specialist to join our team. As a key member of our healthcare team, you will play a critical role in ensuring that our patients receive the most effective and efficient care possible.
Responsibilities- Evaluate medical necessity and appropriateness of healthcare services and treatment
- Work with providers, insurance companies, and patients to ensure cost-effective and appropriate care
- Manage status, medical necessity reviews, verification of authorization, resource utilization, and denial prevention
- Collaborate with attending providers to ensure accurate and timely care
- Enter working diagnosis-related groups (DRGs) in the electronic medical record
- Submit clinical information to payers per payer requirements
- Complete continued stay reviews every 3 days or more often if required
- Communicate with care coordinators for authorized days, level of care, medical necessity, or other areas when indicated
- Communicate with physician advisors related to status concerns or denials
- Update auth/cert screen in the electronic medical record
- Work assigned queues in the electronic medical record
- Communicate with authorization coordinator
- Communicate in-house high dollar case information
- Minimum: RN with 3 years of clinical experience
- Preferred: RN with 3 years of clinical experience
- Education: Diploma or Associate Degree in Nursing
- Preferred: BSN or MSN
- Special Skills: Critical thinking skills, clinical knowledge, attention to detail, communication, organization, interpersonal, time management, and computer skills
- Problem solving; and knowledge of governmental regulations
- Licensure: RN
- Preferred: CCM; ACMA
We are a healthcare organization that values our colleagues and rewards their efforts with competitive compensation and benefits packages. We offer a supportive work environment, continuing education opportunities, and a generous retirement plan. Join our team and be part of a healthcare organization that makes a difference in the lives of our patients and communities.
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