Utilization Specialist

Southwest General • Middleburg Heights, OH

2d

About The Position

POSITION INFORMATION Position summary: The Utilization Specialist is responsible for carrying out admission and concurrent stay screening reviews of the assigned patient population during the episode of care under defined guidelines for acute care case management to ensure the appropriateness of services, utilization of hospital resources, and quality of care rendered. Accurate and efficient application of screening criteria will be applied to identify and support patients being placed in the appropriate hospital level of care via emergency, scheduled, or direct admission processes. Combines clinical, business, and regulatory knowledge and skill to reduce significant financial risk and exposure caused by concurrent and retrospective denial of payments for services provided. Through continuous assessments, problem identification, and education, the Utilization Specialist facilitates the quality of health care delivery in the most cost-effective manner. The Utilization Specialist must be able to demonstrate the knowledge and skills necessary to provide services appropriate to age groups according to specific chronological age, developmental age, and/or psycho-social maturity. The Utilization Specialist will work collaboratively with management, staff, and departments involved in the patient’s plan of care. The Utilization Specialist’s responsibility is to collect data and clinical review summaries on patients concurrently for both utilization review and quality assessment. The utilization data and clinical summaries are shared with insurance companies to obtain certification of days and prevent denial of payment for services. The Utilization Specialist will communicate with physicians, hospital staff, outside agencies such as insurance companies, and patients regarding the assigned level of care and associated resource utilization.

Requirements

• Graduation from an accredited School of Nursing
• Minimum of five (5) years recent experience in clinical nursing or related nursing field. (e.g. Utilization Review or Case Management)
• Excellent critical thinking and communication skills
• Strong computer skills
• Current licensure by Ohio State Board of Nursing

Nice To Haves

• BSN graduate preferred
• Previous Care Management, Case Management or Utilization Management Experience preferred
• Previous experience with screening criteria (i.e. Interqual, MCG) preferred
• ACM/CCM Certification helpful

Responsibilities

• Carrying out admission and concurrent stay screening reviews
• Ensure the appropriateness of services, utilization of hospital resources, and quality of care rendered
• Identify and support patients being placed in the appropriate hospital level of care
• Reduce significant financial risk and exposure caused by concurrent and retrospective denial of payments for services provided
• Facilitate the quality of health care delivery in the most cost-effective manner
• Collect data and clinical review summaries on patients concurrently for both utilization review and quality assessment
• Communicate with physicians, hospital staff, outside agencies such as insurance companies, and patients regarding the assigned level of care and associated resource utilization.

What This Job Offers

• Career Level: Mid Level
• Education Level: Associate degree
• Number of Employees: 501-1,000 employees