Utilization Review (12189)

CULLMAN REGIONAL•Cullman, AL

3d•Onsite

About The Position

Collaborate closely with physicians, nurses, and other members of the care team to gather necessary clinical information and provide guidance on documentation. Support physician provision of patient care with accountability for designated patient case load. Facilitate precertification and payor authorization processes and facilitate collaborative management of patient care across the continuum, intervening as necessary. Conduct timely and thorough concurrent reviews of inpatient admissions to determine medical necessity and appropriateness of the level of care, using evidence-based criteria. Serve as a primary liaison between the hospital and third-party payers, submitting clinical reviews and securing authorizations for continued stays. Identify and escalate cases that do not meet criteria to the Physician Advisor for a secondary review and determination. Actively participate in daily multidisciplinary rounds to discuss patient progress, care plans, and barriers to discharge. Ensure that all review activities are documented accurately and comprehensively within the electronic health record (EHR) and case management systems. Assist in the collection and analysis of utilization data to identify trends and opportunities for process improvement within the hospital. Demonstrate and encourage team behavior and exceptional patient/guest experiences. Uphold and promote patient safety and quality. We are looking for a professional who is passionate about quality care and efficient healthcare delivery. The ideal candidate will possess sharp critical thinking skills and the ability to thrive in a dynamic, team-oriented environment.

Requirements

Must hold a current, unrestricted Registered Nurse (RN) license in the state.
A minimum of three years of recent clinical experience in an acute care setting, such as Med-Surg, ICU, or ER, is required.
Excellent communication and interpersonal skills, with an ability to engage effectively with physicians and payers.
Strong organizational skills and the ability to manage multiple cases simultaneously in a fast-paced setting.
Must be proficient in Microsoft Word and Excel.
Excellent organizational skills are required.
Must be able to set priorities appropriately and handle multiple issues concurrently.

Nice To Haves

A Bachelor of Science in Nursing (BSN) is strongly preferred.
At least two years of direct experience in hospital-based utilization review or case management is highly desirable.
Demonstrated proficiency with clinical criteria sets like InterQual or MCG.

Responsibilities

Gather clinical information and provide guidance on documentation.
Support physician provision of patient care with accountability for designated patient case load.
Facilitate precertification and payor authorization processes.
Conduct concurrent reviews of inpatient admissions to determine medical necessity.
Serve as a liaison between the hospital and third-party payers.
Identify and escalate cases that do not meet criteria to the Physician Advisor.
Participate in daily multidisciplinary rounds.
Ensure accurate documentation within the electronic health record (EHR).
Assist in the collection and analysis of utilization data.
Demonstrate and encourage team behavior and exceptional patient/guest experiences.
Uphold and promote patient safety and quality.