oracle
Clinical Utilization Review Specialist
CHS Career Site
Franklin, USA
Full-time
Mid Level
Onsite
Discovered 1 weeks ago
Free
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- Performs admission and continued stay reviews using evidence-based criteria, clinical expertise, and regulatory guidelines to ensure appropriate utilization of hospital services.
- Collaborates with physicians and clinical teams to obtain necessary documentation for medical necessity, discharge planning, and payer requirements.
- Documents all utilization review activities in the hospital’s case management software, including clinical reviews, escalations, avoidable days, payer communications, and authorization details.
- Works with insurance companies to secure coverage approvals and mitigate concurrent denials by submitting reconsiderations or coordinating peer-to-peer reviews.
- Communicates effectively with utilization review coordinators, case managers, and discharge planners to ensure a collaborative approach to patient care.
- Analyzes trends in hospital admissions and extended stays, identifying opportunities for process improvements to enhance utilization management.
- Serves as a key contact for facility staff and insurance representatives regarding utilization review concerns.
- Supports training initiatives within the department and escalates complex issues to management as needed.
- Performs other duties as assigned.
- Maintains regular and reliable attendance.
- Complies with all policies and standards.
- Associate Degree in Nursing required
- Bachelor's Degree in Nursing preferred
- 2-4 years of clinical experience in utilization review, case management, or acute care nursing required
- 1-3 years work experience in care management preferred
- 1-2 years of experience in utilization management, payer relations, or hospital revenue cycle preferred
- Strong knowledge of utilization management principles, payer guidelines, and regulatory requirements.
- Proficiency in case management software and electronic health records (EHR).
- Excellent communication and collaboration skills to work effectively with interdisciplinary teams and external payers.
- Strong analytical and problem-solving skills to assess utilization trends and optimize hospital resource use.
- Ability to work in a fast-paced environment while maintaining attention to detail and accuracy.
- Knowledge of HIPAA regulations and patient confidentiality standards.
- RN - Registered Nurse - State Licensure and/or Compact State Licensure required
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