About The Position
The RN - Utilization Review Specialist performs utilization review functions independently in accordance with policy and third-party payer requirements. Work includes reviewing medical records, coordinating with healthcare teams and payors, supporting safe and timely inpatient transitions, and helping ensure appropriate reimbursement. The role also supports EPSDT activities as assigned, maintains accurate records, participates in audits and quality improvement, and completes required education and training. This is a PRN position with USA Health Shared Services.
Requirements
- Graduation from an accredited school of nursing meeting the minimum standards set by the State of Alabama.
- At least 2 years of professional nursing experience.
- Registered Nurse state licensure and/or compact state licensure.
- Comparable combinations of education and experience may substitute for the stated requirements.
Nice To Haves
- Bachelor's or Master's degree in nursing.
- Utilization Review experience.
Responsibilities
- Perform quality, prior authorization, initial/admission, continued stay, discharge, retrospective, denial appeal, and case management reviews for DRG payors.
- Analyze medical record data to complete utilization review functions.
- Collaborate with healthcare team members, patients, families, and managed care workers to develop discharge plans and promote safe, timely inpatient flow.
- Apply utilization review functions to support optimal reimbursement from third-party payors.
- Communicate with healthcare providers by telephone, in person, and email about plans of care, length of stay, and stay type.
- Establish and maintain professional relationships with third-party payor representatives.
- Participate in interdisciplinary patient care meetings as assigned.
- Use a PC to access the Hospital Information System.
- Participate in educational programs and complete annual education on nationally recognized level-of-care criteria.
- Participate in utilization review audits as assigned.
- Orient new staff to the utilization review process as assigned.
- Report quality-of-care concerns identified during utilization review to the Director.
- Evaluate chart documentation for completeness against current ICD requirements and communicate deficiencies.
- Perform assigned EPSDT functions, including identifying eligible patients, collecting screening data, performing inter-periodic screening components, and communicating findings to related parties.
- Maintain accurate and complete written, electronic, and paper records; document reviews according to hospital policy.
- Complete and document forms and requests from third-party payors and regulatory parties; document variances, discharge plans, and EPSDT functions.
- Use proper body mechanics when moving equipment needed for essential functions.
- Communicate professionally with physicians, patients, families, and the healthcare team in person and by telephone.
- Respond to overhead pages and accurately access and maintain electronic and paper medical records.
- Participate on committees and in Performance Improvement activities as assigned.
- Complete mandatory department, educational, and hospital requirements; adhere to current infection control and safety standards.
- Maintain regular and prompt attendance, work the defined schedule and overtime as required, and perform related duties as assigned.
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What This Job Offers
Career Level
Mid Level
Education Level
No Education Listed
