Clinical Utilization Review Specialist

4 days ago


Springfield, Massachusetts, United States Trinity Health Of New England Full time
Job Description

At Trinity Health Of New England, we are seeking a skilled Clinical Utilization Review Specialist to join our team. As a key member of our healthcare team, you will be responsible for performing utilization review and payer notification, establishing partnerships with site BPCI RNs, and educating patients and families about financial out-of-pocket expenses.

Key Responsibilities
  • Perform utilization review and payer notification
  • Establish partnerships with site BPCI RNs to align BPCI efforts with patient satisfaction outcomes
  • Educate patients, families, and other members of the care team about financial out-of-pocket expenses
  • Identify and eliminate barriers to effective patient stay management and promote improvements in work processes within the department, hospital, and community
  • Refer quality issues and poor utilization of services to the appropriate sources
  • Educate hospital leadership and staff on current practices, patient coordination issues, and unit-specific trends
  • Provide consultation to professional staff and physicians on level of care determinations, CMS regulations, and payer-specific 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 of experience in similar roles, preferably in a hospital or community-based setting
  • 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

Mercy Medical Center has established itself as one of the leading providers of healthcare services in Western Massachusetts. Our commitment to diversity and inclusion is at the core of our values, and we strive to create a workplace that is welcoming and inclusive for all employees.



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