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Clinical Utilization Review Specialist

1 month ago

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

We are seeking a skilled Clinical Utilization Review Specialist to join our team at Mercy Medical Center. 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 responsibilities.

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 care teams about financial responsibilities
  • Identify and eliminate barriers to effective patient stay management and promote improvements in work processes
  • Refer quality issues and poor utilization of services to 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 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

Mercy Medical Center is a 182-bed acute care hospital in Springfield, Massachusetts. We are committed to providing high-quality patient care and are seeking a skilled Clinical Utilization Review Specialist to join our team.