RN Utilization Review Specialist

2 weeks ago


Memphis, Tennessee, United States Baptist Memorial Healthcare Corporation Full time
Job Summary

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
Requirements
  • 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
About Baptist Memorial Healthcare Corporation

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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