Utilization Review Specialist

1 week ago

Berkeley, California, United States Sutter Health Full time
Job Title: Utilization Review Specialist

Sutter Health is seeking a skilled Utilization Review Specialist to join our team. As a key member of our healthcare team, you will play a critical role in ensuring that patients receive the most appropriate level of care while minimizing unnecessary costs.

Key Responsibilities:
  • Conduct thorough reviews of patient medical records to identify potential barriers to discharge and develop strategies to overcome them.
  • Collaborate with attending psychiatrists and case managers to ensure that patients receive the most appropriate level of care.
  • Provide management and technical expertise in identifying chart documentation problems that impact reimbursement.
  • Track and trend timely appeal/denial data, following up with appropriate staff/departments.
  • Conduct retrospective and current chart review to validate documentation when requested by review agencies.
  • Create, modify, and update data collection parameters, methods of collection, reporting content and format.
  • Review medical records documentation in response to denials or authorizations for level of care issues and length of stay as received from managed care or third party payors.
  • Appeal adverse review decisions, notify appropriate staff when authorization/reimbursement cannot be certified.
  • Provide information to case managers, clinical nursing staff and other departments regarding documentation required for utilization review activities and processes.
  • Collaborate with medical, nursing and other professional personnel to help interpret utilization review program changes and implement revisions to operational procedures.
Requirements:
  • Bachelor's degree in Business Administration or related field.
  • Equivalent experience will be accepted in lieu of the required degree or diploma.
  • Master's in Social Work or related field preferred for Department, Behavioral Health.
  • Working knowledge of medical terminology, including general knowledge of illnesses, current treatments and their physical and psychosocial sequelae.
  • Knowledge of alternate levels of care including criteria required for payment and applications processes.
  • Ability to interpret a variety of data and instructions, furnished in written, oral, diagram, or schedule form.
  • Possess written and verbal communications skills to communicate with fellow team members, supervisors, patients, and other hospital personnel.
  • Well-developed time management and organizational skills, including the ability to prioritize assignments and work within standardized policies and procedures to achieve objectives and meet deadlines.
  • Demonstrated knowledge of computer applications, such as Crystal Report writing, Midas Plus, Excel, Sunrise, MS Word, PCIS, and InterQual.
  • Work independently, as well as be part of the team, including accomplishing multiple tasks in an environment with interruptions.
  • Identify, evaluate and resolve standard problems by selecting appropriate solutions from established options.
  • Ensure the privacy of each patient's protected health information (PHI).
  • Build collaborates relationships with peers and other staff members to achieve departmental and corporate objectives.
Working Conditions:

This is a per diem/casual position with variable hours and as needed weekend requirements. The pay range for this role is $46.29 to $69.44 per hour.

Sutter Health is an equal opportunity employer and welcomes applications from diverse candidates. We are committed to providing a work environment that is free from discrimination and harassment. If you are interested in this opportunity, please submit your application through our website.

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