UR Clinical Specialist (Remote)

Utilization management is the analysis of the necessity, appropriateness, and efficiency of medical services and procedures in the hospital setting. Utilization review is the assessment for medical necessity, both for admission to the hospital as well as continued stay. The Utilization Review Clinical Specialist supports and coordinates the various aspects of the hospital's utilization management program, denials and appeals activities, and readmission reduction initiatives. The nurse specialist will use technology resources to support and monitor authorizations for hospital admissions and extended hospital stays with portals, faxes and phone calls. The Utilization Review Clinical Specialist will monitor adherence to the hospital's utilization review plan to ensure the effective and efficient use of hospital services and monitor the appropriateness of hospital admissions and extended hospitals stays. The specialist will assist the manager in implementing process improvement plans and projects to maximize desired outcomes.

Performs admission and continued stay reviews by utilizing evidence-based criteria, medical experience-based problem-solving skills, and adhering to established policies and regulations governing this process in order to obtain authorization. Collaborates with physicians to obtain necessary documentation for medical necessity, discharge, and payer requirements. These discussions aim to help the UR Clinical Specialist understand the reason for admission and request appropriate additional documentation from the physician(s). Documents all actions and activities related to utilization review in the case management software system used by the hospital. This documentation includes but is not limited to, clinical reviews, escalations, avoidable days, payer contacts, authorization numbers, wDRG, etc. Documentation may also be made in other systems as required based on hospital and/or corporate policies and procedures. Works with insurance companies to ensure coverage and approvals. Mitigate concurrent denials by submitting a reconsideration or arranging a peer-to-peer. Communicates with the UR Coordinators and facility case manager(s) (i.e. licensed social workers, discharge planners, etc.) virtually, and/or through the case management software to ensure effective collaboration between all disciplines managing a patient’s care. Performs problem analysis and resolution as it pertains to the areas of job responsibility. Maintains performance metrics in line with Utilization Review Service Line Key Performance indicators (KPIs). May serve as a key contact for facility and insurance contacts. Maintains confidentiality as it pertains to all Human Resource and Payroll information. May support training within the department. Performs responsibilities that contribute towards meeting or exceeding team goals. Promptly escalate appropriate issues to manager. Provide suggestions and/or recommendations for changes to applicable processes or tools as recognized from functioning in the role on a daily basis. Provides prompt, courteous and accurate customer support. Performs other duties as assigned. Complies with all policies and standards.