Utilization Review Specialist
4 weeks ago
Job Description
ECU Health
About ECU Health Medical Center
ECU Health Medical Center, one of four academic medical centers in North Carolina, is the 974-bed flagship hospital for ECU Health and serves as the primary teaching hospital for The Brody School of Medicine at East Carolina University. ECU Health Medical Center has achieved Magnet designation twice and provides acute and intermediate care, rehabilitation and outpatient health services to a 29-county region that is home to more than 1.4 million people.
Position Summary
The Utilization Review Specialist will ensure regulatory compliance with CMS Conditions of Participation with regard to Utilization Management. Perform Utiliztion Review according to CMS and commercial payor guidelines. Participate in denial / appeal process.
Responsibilities
Utilizes the nursing process to assess, plan, implement and evaluate the utilization management needs for patients in assigned caseload. Performs utilization management activities using approved screening criteria.
Provides follow up with appropriate resource for utilization management issues/non-compliance.
Clinical Progression and Utilization Management. Participates in quality improvement (QI) activities.
Advances knowledge and skills in case / utilization management.
Collaborates effectively with departmental staff to achieve goals and objectives.
Minimum Requirements
Associates Degree in Nursing required; BSN preferred.
NC RN licensure required.
If ADN prepared must have 5 + years experience in an acute care hospital; home health agency; commercial insurance company; case management.
If BSN prepared must have 3-5 years experience in an acute care hospital; home health agency; commercial insurance company; case management.
A certification in Case Management (i.e. CCM, ACM) can substitute for 1 year of experience; Masters Degree in health related field can substitute for 1 year of experience.
Other Information
Shift: 10 hour days with weekend rotation in the Emergency Department
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Greenville, United States ECU Health Full timeECU Health Physicians and ECU Health Medical Center, located in Greenville, North Carolina, are seeking a Physician Assistant to work as a Utilization Review Advisor. The successful applicants will be a part of ECU Health Clinical Documentation Advisor Program, with close working relationships with both the utilization review and appeals staff. Applicants...
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Greenville, United States ECU Health Full timeECU Health Physicians and ECU Health Medical Center, located in Greenville, North Carolina, are seeking a Physician Assistant to work as a Utilization Review Advisor. The successful applicants will be a part of ECU Health Clinical Documentation Advisor Program, with close working relationships with both the utilization review and appeals staff. Applicants...
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Greenville, United States ECU Health Full timeNP/PA Utilization Review Advisor Opportunity in Greenville, NC (Partial Remote)ECU Health Physicians and ECU Health Medical Center, located in Greenville, North Carolina, are seeking a Nurse Practitioner or Physician Assistant to work as a Utilization Review Advisor. The successful applicants will be a part of ECU Health Clinical Documentation Advisor...
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Greenville, United States ECU Health Full timeNP/PA Utilization Review Advisor Opportunity in Greenville, NC (Partial Remote) ECU Health Physicians and ECU Health Medical Center, located in Greenville, North Carolina, are seeking a Nurse Practitioner or Physician Assistant to work as a Utilization Review Advisor. The successful applicants will be a part of ECU Health Clinical Documentation Advisor...
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