utilization reviewer

Blue Cross Blue Shield of Massachusetts

Ready to help us transform healthcare? Bring your true colors to blue.
<br>The Role
<br>The Physical Therapy Utilization Management Reviewer is responsible for evaluating the appropriateness and medical necessity of outpatient rehabilitation and other services within scope of practice per business needs. The reviewer will ensure services align with established clinical guidelines and policies.
<br>This position is part of a larger team and works independently and collaboratively to facilitate care using clinical skills, principles of managed care, nationally recognized medical necessity criteria, and company medical policies to conduct reviews that promote efficient and medically appropriate use of the member’s benefit to provide the best quality care.
<br><br>
The Team
<br>The commercial Physical Therapy Utilization Management Reviewer is part of a highly dedicated and motivated team of professionals. The team includes clinicians, medical and behavioral health care managers, dietitians, pharmacists, medical directors and more, who collaborate to facilitate care.
<br><br>
This position is eligible for the Mobile persona with an in-office requirement to work at our Hingham location 2x/month.
<br><br>
<b>Key Responsibilities:</b><br>
Conduct pre-certification, concurrent, and retrospective reviews with emphasis on utilization management, discharge planning, care coordination, clinical outcomes, and quality of service.
<br>Evaluate members’ clinical status, benefits, and appropriateness for programs and sites of service to develop a cost-effective, medically necessary plan of care.
<br>Successfully complete/pass the annual InterQual Interrater Reliability Test.
<br>Interact with treating providers, PCPs, physicians, therapists, and facilities as needed to gather clinical information to support the plan of care.
<br>Monitor clinical quality concerns and make appropriate referrals regarding concerns to the appropriate internal departments.
<br>Understand member insurance products and benefits and apply benefits appropriately
<br>Learn and implement regulatory guidelines related to compliance and regulatory requirements (examples: NCQA, Department of Insurance).
<br>Other duties as assigned and based on business needs.
<br><br>
<b>Key Qualifications:</b><br>
Able to work Independently and collaboratively on a team, adaptable and flexible to change.
<br>Ability to communicate effectively.
<br>Ability to manage ambiguity and assess, analyze, and determine next steps.
<br>Critical thinking and clinical judgment.
<br>Proficient with multiple IT systems.
<br>Demonstration of awareness, attitude, knowledge, and skills needed to work effectively with a culturally and demographically diverse population.
<br><br>
<b>Education and Experience:</b><br>
3-5 years relevant experience in a variety of appropriate clinical health care settings (outpatient rehabilitation inpatient acute or lower levels of care or differing clinical rehabilitation settings with transferable skills and experience.
<br>Utilization Management experience, preferred.
<br>Active licensure in Massachusetts is required, appropriate to position (PT).
<br>Licensure in additional states a plus.
<br><b>Note:</b> Any restrictions against a license must be disclosed and reviewed.
<br><b>Credentials:</b> Doctor of Physical Therapy (DPT) degree, Master’s in Physical Therapy (MSPT) or Bachelor’s in Physical Therapy (BSPT) from a program accredited by the Commission on Accreditation in Physical Therapy Education (CAPTE).
<br><br>
<b>Minimum Education Requirements:</b><br>
High school degree or equivalent required unless otherwise noted above
<br><br>
Location Hingham Time Type Full time
<br><br>
<b>Hourly Range:</b> $42.18 - $51.56
<br><br>
The job posting range is the lowest to highest salary we in good faith believe we would pay for this role at the time of this posting. We may ultimately pay more or less than the posted range, and the range may be modified in the future. An employee’s pay position within the salary range will be based on several factors including, but limited to, relevant education, qualifications, certifications, experience, skills, performance, shift, travel requirements, sales or revenue-based metrics, and business or organizational needs and affordability.
<br><br>
This job is also eligible for variable pay.
<br><br>
We offer comprehensive package of benefits including paid time off, medical/dental/vision insurance, 401(k), and a suite of well-being benefits to eligible employees.
<br><br>
<b>Note:</b> No amount of pay is considered to be wages or compensation until such amount is earned, vested, and determinable. The amount and availability of any bonus, commission, or any other form of compensation that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law.
<br><br>
WHY Blue Cross Blue Shield of MA?
<br>We understand that the confidence gap and imposter syndrome can prevent amazing candidates coming our way, so please don’t hesitate to apply. We’d love to hear from you. You might be just what we need for this role or possibly another one at Blue Cross Blue Shield of MA. The more voices we have represented and amplified in our business, the more we will all thrive, contribute, and be brilliant. We encourage you to bring us your true colors, , your perspectives, and your experiences. It’s in our differences that we will remain relentless in our pursuit to transform healthcare for ALL.
<br><br>
As an employer, we are committed to investing in your development and providing the necessary resources to enable your success. Learn how we are dedicated to creating an inclusive and rewarding workplace that promotes excellence and provides opportunities for employees to forge their unique career path by visiting our Company Culture page. If this sounds like something you’d like to be a part of, we’d love to hear from you. You can also join our Talent Community to stay “in the know” on all things Blue.
<br><br>
At Blue Cross Blue Shield of Massachusetts, we believe in wellness and that work/life balance is a key part of associate wellbeing. For more information on how we work and support that work/life balance visit our " How We Work " Page.

PT Utilization Management Reviewer

Asante

<p></p><div><div><div><p><b>Req #:</b> 24661<br>
<b>Entity:</b> Asante Rogue Regional Medical Center<br>
<b>Location:</b> Medford OR<br>
<b>Department:</b> Case Management<br>
<b>Shift:</b> Variable Schedule Days<br>
<b>Union Position:</b> No<br>
<b>FTE:</b> 0.000001<br>
<b>Schedule:</b> On Call<br>
<b>Salary:</b> $23.28 - $32.02 depending on qualifications</p></div><p></p><div><div><br>
</div></div></div><div><p><b>Description</b>
</p><p><b>Additional Position Details: FTE: 0.000001 | On Call | Variable Schedule Days</b></p><p><b>
Starting Wage</b>: $23.28-$32.02 per hour, depending on experience</p><p></p><p><b>
Position Summary</b></p><p>
The <b>Case Management Specialist </b>functions as a member of the Case Management team. They utilize communication, organizational, and problem-solving skills to carry out the post-hospital care plans and interventions, utilization review, and denials management activities as defined by the RN Discharge Coordinator and RN Utilization Reviewer. They assume a pivotal role with the patient care team to achieve optimal clinical and resource outcomes.</p><p></p><p><b>
Position Qualifications</b></p><p><b>
Experience</b></p><p></p><ul><li>
3 years of experience in administrative functions in care coordination and/or utilization management in healthcare settings is required.</li><li>
Experience with Microsoft Word and Excel is required</li><li>
Experience with EPIC is preferred</li><li>
Current understanding of CMS regulations related to hospital discharge requirements is preferred.</li></ul><p><b>
Education</b></p><p></p><ul><li>
High School Diploma, GED, or equivalent experience demonstrating the ability to effectively communicate as required for the position is required</li><li>
An Associate's degree in business, healthcare administration, or a related field is preferred</li></ul><p><b>
Total Rewards</b></p><p></p><p>
We offer a comprehensive Total Rewards package designed to support your well-being and professional growth, including:</p><p></p><ul><li><b>
Competitive Pay: </b>Hourly and salaried positions earn market-based compensation.</li><li><b>
Health &amp; Wellness: </b>Medical, dental, and vision coverage for part-time and above employees and their eligible dependents beginning within 30 days of hire.</li><li><b>
Retirement Savings: </b>Employer-sponsored retirement plan with company contribution and match.</li><li><b>
Paid Time Off: </b>Generous ETO for part-time and above employees.</li><li><b>
Professional Development: </b>Continue to enhance your education through our tuition reimbursement and tuition repayment program</li><li><b>
Additional Benefits: </b>Life insurance, disability coverage, and employee assistance programs.</li></ul><p></p><p>
At Asante, we are guided by our values:</p><p><b>
Excellence - Respect - Honesty - Service - Teamwork</b></p><p></p><p><i>
Asante is proud to be an Equal Opportunity Employer. We are committed to creating a diverse and inclusive workplace and to employing and advancing qualified individuals of all backgrounds, including women, minorities, individuals with disabilities, and protected veterans.</i></p></div></div><p></p>

Case Management Specialist

NeuroPsychiatric Hospitals

<div>About Us:
<h3 class="jobSectionHeader"><b>Healing Body and Mind.</b></h3><div>
NeuroPsychiatric Hospitals is a national leader in behavioral healthcare, specializing in patients with acute psychiatric and complex medical needs. Our hospitals use an interdisciplinary, multi-specialty approach that delivers high-quality, patient-centered care when it&rsquo;s needed most.</div><div>
With locations in <b>I</b>ndiana, Michigan, Texas, and Arizona, we&rsquo;re expanding access to our unique model of care across the United States. Join us and be part of a team dedicated to making a lasting difference in the lives of patients and families every day</div>
Overview:
<div>
NeuroPsychiatric Hospital of Indianapolis is looking for a Utilization Review Coordinator to coordinate patients&rsquo; services across the continuum of care by promoting effective utilization, monitoring health resources and elaborating with multidisciplinary teams.</div><div></div><div><b><br>
Benefits of joining NPH</b></div><ul><li>
Competitive pay rates</li><li>
Medical, Dental, and Vision Insurance</li><li>
NPH 401(k) plan with up to 4% Company match</li><li>
Employee Assistance Program (EAP) Programs</li><li>
Generous PTO and Time Off Policy</li><li>
Special tuition offers through Capella University</li><li>
Work/life balance with great professional growth opportunities</li><li>
Employee Discounts through LifeMart</li></ul>
Responsibilities:
<ul><li>Filing documents as needed.</li><li>
Initial Precertification with payors.</li><li>
Concurrent Clinical review with payors.</li><li>
Document in the electronic system daily in real time.</li><li>
Admission audit.</li><li>
Ensures that CON&rsquo;s/RON&rsquo;s and CMS certifications are completed by provider.
</li><li>Consistently demonstrates professionalism with all internal and external customers as evidenced by positive customer and peer Communicates effectively with all staff and patients as evidenced by the establishment and maintenance of productive working relationships.</li><li>
Maintains knowledge of current trends and developments in the field by reading appropriate books; journals and other literature and attending related seminars or conferences.</li><li>
Maintains a professional approach with Assures protection and privacy of health information as attained through written, electronic or oral disclosures.</li><li>
Cooperates and maintains good rapport with nursing staff, medical staff, and other departments.</li><li>
Seeks guidance and remains knowledgeable of, and complies with, all applicable federal and state laws, as well as hospital polices that apply.</li><li>
Complies with hospital expectations regarding ethical behavior and standards of conduct.</li><li>
Complies with federal and hospital requirements in the areas of protected health information and patient information.</li><li>
Reconsiderations, assists with appeals as needed, arrange peer to peer level reviews, and report the outcomes to the VP of Care Management and Team.</li><li>
Provides education to nursing staff. ;eadership team, and providers regarding documentation.</li><li>
Actively works with the business office regarding resolution of appeals/denials and retrospective reviews.</li></ul>
Qualifications:
<p>
Education: Bachelor's in Behavioral Health, Social Work, Counseling, Nursing or Psychology required. Master's degree preferred.</p><p>
Experience: <b>Minimum of 2 years of utilization review experience in a hospital setting required.</b> Minimum of 2 years of case management experience, including discharge planning in a hospital setting required.</p><div>
Licensure: Certified Case Manager (CCM) or Accredited Case Manager (ACM) preferred. Basic Life Support (BLS) and Handle with Care (HWC) obtained during orientation, if applicable.</div><div>
Skills: Must have strong knowledge of medications and demonstrate exceptional time management, data entry, and communication skills. Must be detail oriented.#INDEEDLOW</div></div>

Utilization Review Coordinator

University of Maryland Medical System

<div><b>Job Requirements<br>
</b><br>
<p><b>Job Summary
</b></p><p>Utilization Review coordinates the care and service of selected patient populations across the continuum. He/ she works collaboratively with physicians and other members of the health care team to achieve the highest quality clinical outcomes with the most cost-effective use of available resources. Utilization Review assumes responsibility for an interdisciplinary process which assesses, plans, implements, monitors and measures the effectiveness of interventions to meet patients&rsquo; treatment and transitional needs.</p><p><b><br>
COLLABORATION: </b>Collaborates with the physician and other healthcare professionals to promote appropriate use of medical center resources. Participates as a team member to facilitate communication among all disciplines, identify barriers to meeting treatment goals, and determines ways to achieve best outcomes. Participates in the hospital Ethics Committee, as well as facilitates the hospital UR committee.</p><p><b>
DOCUMENTATION AND MEASUREMENT: </b>Uses established criteria to determine appropriateness of admissions, transfer and continued stays. Documents actions in medical record according to departmental guidelines and oversees process of exchange of information with other facilities/ agencies adhering to legal mandates regarding confidentiality. Measures effectiveness of interventions through direct communication with patients and caregivers and data collection of defined indicates (e.g. overall length of stay, readmission rates, feedback from referral services, etc.).</p><p><b>
PATIENT CARE: </b>Uses severity of illness/ intensity of services indexes to determine appropriateness of admissions, transfers and continued stays. Provides physicians and ancillary departments with data on treatment outcomes and avoidable delays in order to promote highest quality care. Identifies potential areas of compliance vulnerability and risk; develops and implements corrective action plans for resolution of problematic issues; and provides general guidance on how to avoid or deal with similar situations in the future. Measures effectiveness of interventions through direct communication with patients and caregivers and data collection of defined indicators (e.g. overall length of stay, readmission rates, feedback from referral sources, etc.). Plays and active leadership role in the ongoing management of inpatient length of stay and utilization review across the organization.</p><p><b>
PROBLEM SOLVING: </b>Identifies problems or gaps in community resources that impact outcome and takes leadership role in efforts to effect changes. Takes a leadership role in identifying opportunities to reduce risks, both financial and clinical, through analysis of resource consumption outcomes.</p><b><br>
Work Experience<br>
</b><br>
<p><b>Education
</b></p><ul><li>4 year/ Bachelor's degree in Nursing (Required)</li></ul><p>
Combination of relevant education and experience may be considered in lieu of degree.</p><p>
Master's Degree in Nursing (Preferred)</p><p><b><br>
Certification / Licensure / Registration</b></p><p>
Case Management Certification (Preferred)</p><p><b><br>
Experience and Skills Required Skills:
</b></p><p>Strong Verbal Communications Skills, Strong Written Communications Skills, Excel - Intermediate Level, PowerPoint - Intermediate Level, MS Word - Intermediate Level, Excellent Organizational Skills</p></div>

Utilization Review RN

PrairieCare

<div>About Us:
<div><b>
Join PrairieCare: Transform Lives Through Meaningful Work!</b></div><div></div><div><br>
Are you ready to embark on a rewarding career in psychiatric healthcare? At PrairieCare, we are passionate about delivering exceptional mental health services to individuals in need. Our comprehensive approach covers the entire spectrum of care, creating a wealth of diverse roles for those who aspire to make a real impact.</div><div>
We believe in nurturing talent and fostering professional growth in a supportive environment. Here, you won&rsquo;t just find a job&mdash;you&rsquo;ll discover a fulfilling career path in the mental health field.</div><div>
If you're eager to contribute to a mission-driven organization and help change lives for the better, we invite you to join our dedicated team at PrairieCare. Together, we can make a profound difference in the lives of those we serve!</div>
Responsibilities:
<div>
 <b>Join Our Dynamic Team as a Utilization Review Specialist</b></div><div></div><div><br>
Are you passionate about making a difference in the lives of those with psychiatric illnesses? Do you thrive in a collaborative environment where your expertise can shine? If so, we have the perfect opportunity for you!</div><div></div><div><b><br>
What You'll Do:</b> As our Behavioral Health Liaison, you will be the vital link between our dedicated clinical treatment team and third-party payers, ensuring that every patient receives the appropriate treatment they deserve. Your role will include:</div><div>
✅ <b>Securing Authorizations:</b> Obtain initial behavioral health authorizations and conduct thorough concurrent reviews to keep our patients on the path to recovery.</div><div>
✅ <b>Collaborative Decision-Making:</b> Work closely with the clinical treatment team to assess the need for denial of stay when patients no longer meet acute care criteria, facilitating timely and appropriate actions.</div><div>
✅ <b>Stay Informed:</b> Maintain an up-to-date understanding of contract requirements for all third-party payor groups, ensuring compliance and optimal patient care.</div><div>
✅ <b>Track Progress:</b> Monitor each patient&rsquo;s treatment journey through inpatient, partial hospitalization, and Intensive Outpatient Programs (IOP), ensuring they receive the best possible support.</div><div>
✅ <b>Cultural Competence:</b> Bring your knowledge of gender, cultural differences, and age-appropriate care to the forefront of Utilization Review, enhancing our approach to diverse patient needs.</div><div><b>
Why Join Us?</b> At our organization, you&rsquo;ll be part of a passionate team committed to improving mental health care. We value your expertise and provide ongoing training and support to help you excel in your role.</div><div>
 <b>Make a Difference Today!</b> If you&rsquo;re ready to take on a rewarding challenge and be a champion for those in need, apply now and help us transform lives through compassionate care!</div><div></div><div><br>
We are excited to hear about your interest in this opportunity! If you have any questions or need assistance with the application process, please feel free to contact me directly at <b>Sydney Spencer</b>, either via email at <b>sydney.spencer@newporthealthcare.com</b> or by phone at <b>615-961-4138</b>. If you need further support, you are also welcome to reach out to our careers and management team at <b>careers@newporthealthcare.com</b><b>.</b>
</div>Qualifications:
<div><b>
What You'll Bring:</b></div><div></div><ul><li><br>
At least two (2) years of work experience in the behavioral health field.
</li><li>Active license or credential in a behavioral health field preferred.
</li><li>Bachelor&rsquo;s or Master&rsquo;s in a behavioral health related specialty preferred.</li></ul><p></p><div><b><br>
Benefit options include:</b></div><ul><li>
Medical/Dental/Vision</li><li>
Company paid life insurance</li><li>
Paid time off including sick time</li><li>
Voluntary Short term and long-term disability</li><li>
401K with company match</li><li>
Flexible spending accounts</li><li>
Tuition Reimbursement</li><li>
Student Loan Repayment</li><li>
Free parking</li><li>
Free 24/7 Fitness Center</li></ul><div><b>
Join Us:</b></div><div>
Join us in our mission to provide outstanding support and make a meaningful difference in the lives of those we assist. Your contributions can help shape the future of our care services&mdash;apply today!</div><div></div><p><br>
PrairieCare Healthcare is an Equal Opportunity Employer.</p><p>
PrairieCare provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, sexual orientation, gender identity, national origin, disability status, protected veteran status, genetic information, or any other characteristic protected by federal, state, or local laws.</p><p>
PrairieCare is committed to ensuring equal employment opportunity, including providing reasonable accommodations to individuals with disabilities. Applicants with a physical or mental disability who require a reasonable accommodation for any part of the application or hiring process are encouraged to email careers@newporthealthcare.com for assistance.</p><p></p><div><br>
#LI-SS1</div></div>

Utilization Review Specialist (or UR Nurse)

<div>About Us:
<h3 class="jobSectionHeader"><b>Healing Body and Mind.</b></h3><div>
NeuroPsychiatric Hospitals is a national leader in behavioral healthcare, specializing in patients with acute psychiatric and complex medical needs. Our hospitals use an interdisciplinary, multi-specialty approach that delivers high-quality, patient-centered care when it&rsquo;s needed most.</div><div>
With locations in <b>I</b>ndiana, Michigan, Texas, and Arizona, we&rsquo;re expanding access to our unique model of care across the United States. Join us and be part of a team dedicated to making a lasting difference in the lives of patients and families every day</div>
Overview:
<div><b>
Medical Behavioral Hospital of Clear Lake</b> is looking for a Utilization Review Coordinator to coordinate patients&rsquo; services across the continuum of care by promoting effective utilization, monitoring health resources and elaborating with multidisciplinary teams.</div><div></div><div><b><br>
Benefits of joining NPH</b></div><ul><li>
Competitive pay rates</li><li>
Medical, Dental, and Vision Insurance</li><li>
NPH 401(k) plan with up to 4% Company match</li><li>
Employee Assistance Program (EAP) Programs</li><li>
Generous PTO and Time Off Policy</li><li>
Special tuition offers through Capella University</li><li>
Work/life balance with great professional growth opportunities</li><li>
Employee Discounts through LifeMart</li></ul>
Responsibilities:
<ul><li>Filing documents as needed.</li><li>
Initial Precertification with payors.</li><li>
Concurrent Clinical review with payors.</li><li>
Document in the electronic system daily in real time.</li><li>
Admission audit.</li><li>
Ensures that CON&rsquo;s/RON&rsquo;s and CMS certifications are completed by provider.
</li><li>Consistently demonstrates professionalism with all internal and external customers as evidenced by positive customer and peer Communicates effectively with all staff and patients as evidenced by the establishment and maintenance of productive working relationships.</li><li>
Maintains knowledge of current trends and developments in the field by reading appropriate books; journals and other literature and attending related seminars or conferences.</li><li>
Maintains a professional approach with Assures protection and privacy of health information as attained through written, electronic or oral disclosures.</li><li>
Cooperates and maintains good rapport with nursing staff, medical staff, and other departments.</li><li>
Seeks guidance and remains knowledgeable of, and complies with, all applicable federal and state laws, as well as hospital polices that apply.</li><li>
Complies with hospital expectations regarding ethical behavior and standards of conduct.</li><li>
Complies with federal and hospital requirements in the areas of protected health information and patient information.</li><li>
Reconsiderations, assists with appeals as needed, arrange peer to peer level reviews, and report the outcomes to the VP of Care Management and Team.</li><li>
Provides education to nursing staff. ;eadership team, and providers regarding documentation.</li><li>
Actively works with the business office regarding resolution of appeals/denials and retrospective reviews.</li></ul>
Qualifications:
<p>
Education: Bachelor's in Behavioral Health, Social Work, Counseling, Nursing or Psychology required. Master's degree preferred.</p><p>
Experience: Minimum of 2 years of utilization review experience in a hospital setting required. Minimum of 2 years of case management experience, including discharge planning in a hospital setting required.</p><div>
Licensure: Certified Case Manager (CCM) or Accredited Case Manager (ACM) preferred. Basic Life Support (BLS) and Handle with Care (HWC) obtained during orientation, if applicable.</div><div>
Skills: Must have strong knowledge of medications and demonstrate exceptional time management, data entry, and communication skills. Must be detail oriented.#INDEEDLOW</div></div>

Emory Healthcare

<div>Overview:
<div><b>
Be inspired. Be rewarded. Belong. At Emory Healthcare.</b></div><div></div><div><br>
At Emory Healthcare we fuel your professional journey with better benefits, valuable resources, ongoing mentorship and leadership programs for all types of jobs, and a supportive environment that enables you to reach new heights in your career and be what you want to be. We provide:</div><ul><li>
Comprehensive health benefits that start day 1</li><li>
Student Loan Repayment Assistance &amp; Reimbursement Programs</li><li>
Family-focused benefits
</li><li>Wellness incentives</li><li>
Ongoing mentorship, development, leadership programs and... more!</li></ul>
Description:
<div>
Job Summary: The Utilization Review (UR) Specialist is a Registered Nurse responsible for conducting thorough medical necessity reviews to assist with determining appropriate patient class designation. The UR Specialist will perform timely and comprehensive reviews of the patient chart utilizing InterQual Criteria accurately in conjunction with the UR Department workflows/processes, clinical nursing judgement, and when necessary, discussions with the provider team and/or Medical Director of UR. Primary duties and responsibilities: Operational Support: 1. Conducts thorough medical necessity reviews to assist with determining appropriate patient class designation. 2. Performs timely and comprehensive reviews of the patient chart utilizing InterQual Criteria accurately in conjunction with the UR Department workflows/processes, clinical nursing judgement, and when necessary, discussions with the provider team and/or Medical Director of UR. 3. Performs appropriate and accurate initial, admission (episode day one) and concurrent utilization reviews as guided by InterQual Criteria and UR Department workflows on all observation, inpatient, and extended recovery admissions as required based on Emory Healthcare's Utilization Management Plan and the UR Department&Acirc;&iquest;s processes. 4. Ensures that all InterQual reviews are supported with provider team documentation and/or clinical data. 5. When appropriate, the UR Specialist will utilize the UR Department's Severity of Illness/Intensity of Service template to document the medical necessity of the admission or continued stay. 6. While conducting utilization reviews, will identify any Avoidable Delays and accurately document the delay(s) based on the workflow. 7. Follow the UR Department&Acirc;&iquest;s denial workflows as appropriate. 8. Prioritizes work with minimal guidance for optimal reimbursement and to avoid financial risk to both patient and hospital. Compliance: 1. Will identify and complete Medicare Outpatient Observation Notices (MOON), Medicare Change of Status Notice (MCSN), Condition Code 44s and Medicare Hospital Issued Notices of Non-Coverage (HINNs) for Medicare beneficiaries as appropriate. 2. Ensures compliance with all state of Georgia and Federal regulatory requirements as designated in Emory Healthcare's Utilization Management Plan. 3. Maintains all required annual competencies, metrics, and fully participate and engage in department process improvements. Collaboration: 1. Responsible for timely communication to the provider team and interdisciplinary team as it relates to patient class designation and medical necessity of an admission or continued stay on individual patient basis based on UR Department workflows. 2. In a team effort, the UR Specialist will work closely with the UR Department's Case Management Authorization Specialist IP to ensure that authorized days and patient actual LOS are reconciled to ensure appropriate reimbursement for services provided. 3. Responsible for communicating medical necessity denials for in-house patients to the Medical Director of UR, and when designated to the provider team. 4. Serves as a resource to the provider team, Interdisciplinary Care Team, and patient to explain external UR regulations. 5. Provides effective and efficient proactive communication to internal and external customers. 6. Assists in collaborative efforts with the Case Management Department, Revenue Cycle, Physician Advisors, and other required departments. Additional Responsibilities: 1. Ability to multi-task in a fast-paced environment while efficiently handling multiple priorities and ensuring deadlines are met. 2. Performs other duties and tasks as assigned. Travel: Less than 10% of the time may be required. Work Type: This position is a remote position outside traditional office, often from home or another remote setting.
<br>
<br>
Minimum Qualifications: Education - Associate degree in nursing. Experience - Minimum of 5 years of recent acute hospital experience or a minimum of two years of previous utilization review experience. Licensure - Must have a valid, active unencumbered Registered Nurse license approved by the Georgia Licensing Board. Skills - Must meet all quality and productivity expectations and successfully complete yearly competencies. Preferred Qualifications: Education - Bachelor's degree in Nursing strongly preferred. Certification - Case Management certification preferred. Skills - InterQual Level of Care Criteria experience. Previous utilization review experience strongly preferred.
<br>
<br>
PHYSICAL REQUIREMENTS: Occasional to frequent sitting. Close eye work (computers, typing, reading, writing).
<br>
<br>
ENVIRONMENTAL FACTORS: Remote position.</div>
Additional Details:
<div>
Emory is an equal opportunity employer, and qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, protected veteran status or other characteristics protected by state or federal law.</div><div></div><div><br>
Emory Healthcare is committed to providing reasonable accommodations to qualified individuals with disabilities upon request. Please contact Emory Healthcare&rsquo;s Human Resources at careers@emoryhealthcare.org. Please note that one week's advance notice is preferred.</div></div>

Utilization Review Specialist

Search 2098+ Utilization reviewer jobs near you this April. New roles added regularly across leading industries. Apply today.

2098 utilization reviewer jobs Near Me

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Utilization Review RN

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Utilization Review Coordinator

Utilization Review Specialist