RN - Utilization Review Specialist (On-Site)
US-IA-Cedar Rapids
careers
Req #: 174223
Type: Full Time Benefits
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Overview: This position is on site at St. Luke's Hospital. The Utilization Management Specialist in the Behavioral Health Hospital Outpatient Departments serves a key role in coordinating the department's interdisciplinary effort to assess and promote appropriate utilization of health care resources, provision of high-quality health care, optimal clinical outcomes and patient and provider satisfaction. The UM Specialist provides the Utilization Management function for patients admitted to BH HODs effective utilization of resources through ongoing interactions with physicians, third party payers and regulatory agencies. The UM spcialist will also be called upon to provide clinical and nursing expertise and support within the HOD departments, when appropriate. Responsibilities: Utilization Management * Addresses and monitors length of stay issues and level of care changes for compliance * Documents the case management plan to include: clinical needs, barriers to quality care, effective utilization of resources and pursues denials of payment and referrals in a timely, legible manner. * Collects appropriate data, trends, analyzes and reports on patterns of care, possible avoidable delays in transition, variance from pathways and resource utilization Revenue Cycle * Communicates effecively with thrird party payers regarding authorization of stay, continued stay reviews, appeals and denial letters. * Provides education and serves as a resource to the multidisciplinary team in regards to level of care and reimbursement issues. * Documents within the electronic medical record including financial notations and letters when appropriate. * Collects appropriate data, trends, analyzes and reports on patterns of care, possible avoidable delays in transition, variance from pathways and resource * Demonstrates a working knowledge of financial and reimbursement processes to facilitate medical cost management, including best practices, effective utilization of resources, linking clinical and financial aspects of care, and access to care and level of care. * Serves as a resource and educator to patient, family, staff and physicians regarding financial aspects of individual patient's resources which may affect the transition of patients through the healthcare system. * Provides education for the individual and family and for the team regarding benefits, utilization of resources, levels of care, and expectations of the transition process throughout settings across the healthcare continuum. Facilitates empowerment of the patient and family in self-management and health care decision-making. Qualifications: * State of Iowa Licensed RN * Two years of behavioral health work experience. * Professional communication - written & verbal * Microsoft Office proficiency (Outlook, Word, Excel) * Customer/patient focused * Self-motivated * Ability to work with minimal supervision * Ability to manage priorities/deadlines * Ability to multi-task and prioritize workload * Flexible and adaptable to changing environment * Excellent critical thinking and problem-solving skills * Positive attitude with team-oriented approach * Ability to give work direction to non-clinical staff * Use of usual and customary equipment used to perform essential functions of the position.
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