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Healthcare Utilization Review Analyst

2 months ago

Columbia, Missouri, United States Lexington Medical Center Full time

Department: Utilization Management
Employment Type: PRN
Shift: Rotating
Schedule: Variable

About Lexington Medical Center: Consistently recognized as a leading healthcare provider, Lexington Medical Center is dedicated to delivering exceptional health services tailored to the needs of our communities. As the top-ranked hospital in the Columbia metro area according to U.S. News & World Report, we take pride in being one of the Best Places to Work in South Carolina.

Facility Overview: Our 607-bed teaching hospital serves as the cornerstone of a comprehensive healthcare network that includes six community medical centers and a workforce of over 8,700 healthcare professionals. Our network features a distinguished cardiovascular program, accredited Cancer Center of Excellence, and various specialized care facilities, including an Alzheimer’s care center and an extensive array of physician practices.

Position Summary: The Utilization Review Specialist is responsible for conducting admission and concurrent stay medical record evaluations to assess the appropriateness of patient admissions, continued stays, and care settings. This role involves collaboration with attending physicians and healthcare providers throughout the patient's hospitalization, ensuring effective communication with third-party payers to secure necessary authorizations. The specialist plays a vital role in optimizing patient throughput and length of stay while assisting in denial management and ensuring the completeness of physician documentation.

Qualifications:

  • Education: ADN, Diploma Nursing Degree, or Bachelor of Science in Nursing
  • Experience: Minimum of 3 years in an acute care hospital environment
  • Licensure: Active Registered Nurse license in South Carolina

Key Responsibilities:

  • Foster positive relationships with patients, families, and colleagues through effective communication and teamwork.
  • Demonstrate professionalism and pride in representing Lexington Medical Center positively.
  • Engage in conflict resolution and problem-solving with a calm and constructive approach.
  • Maintain confidentiality and discretion in all patient-related matters.
  • Conduct thorough reviews of admissions using established criteria to ensure appropriate care level assignments.
  • Document clinical data accurately and maintain compliance with regulatory guidelines.
  • Serve as a liaison between physicians and third-party payers, ensuring clear communication regarding patient care and reimbursement issues.
  • Participate in interdisciplinary patient care conferences and discharge planning activities.

Benefits: Lexington Medical Center is committed to providing quality, cost-effective benefits for employees and their families, including:

  • Comprehensive medical, dental, and life insurance from day one
  • Flexible spending accounts for healthcare and dependent care
  • 403(b) retirement plan with employer matching
  • Employer-paid life insurance
  • Tuition reimbursement and student loan forgiveness programs

Equal Opportunity Employer: Lexington Medical Center is dedicated to providing equal employment opportunities and fostering a discrimination-free workplace, in compliance with all applicable laws and regulations.