What are the responsibilities and job description for the Utilization Review Specialist position at Park Royal Hospital?
PURPOSE STATEMENT:
Proactively monitor utilization of services for patients to optimize reimbursement for the facility.
ESSENTIAL FUNCTIONS:
- Act as liaison between managed care organizations and the facility professional clinical staff.
- Conduct reviews, in accordance with certification requirements, of insurance plans or other managed care organizations (MCOs) and coordinate the flow of communication concerning reimbursement requirements.
- Monitor patient length of stay and extensions and inform clinical and medical staff on issues that may impact length of stay.
- Gather and develop statistical and narrative information to report on utilization, non-certified days (including identified causes and appeal information), discharges and quality of services, as required by the facility leadership or corporate office.
- Conduct quality reviews for medical necessity and services provided.
- Facilitate peer review calls between facility and external organizations.
- Initiate and complete the formal appeal process for denied admissions or continued stay.
- Assist the admissions department with pre-certifications of care.
- Provide ongoing support and training for staff on documentation or charting requirements, continued stay criteria and medical necessity updates.
OTHER FUNCTIONS:
- Perform other functions and tasks as assigned.
EDUCATION/EXPERIENCE/SKILL REQUIREMENTS:
- Associate's degree required. Bachelor's or Master’s degree in social work, behavioral or mental health, nursing or other related health field preferred.
- Two or more years' experience with the population of the facility and previous experience in utilization management preferred.
LICENSES/DESIGNATIONS/CERTIFICATIONS:
- Current Florida licensure as an LPN or RN preferred; or current clinical professional license or certification.
- CPR and de-escalation and restraint certification required (training available upon hire and offered by facility.
Experience
Preferred- Two or more years' experience with the population of the facility and previous experience in utilization management preferred
Education
Required- Associates or better
- Masters or better in Social Work
- Bachelors or better in Social Work
Licenses & Certifications
Required- Lic Practical Nurse
- Reg Nurse
Skills
Preferred- Safety Minded
- Problem Solving
- Oral Communication
- Communication
- Attention to Detail
Behaviors
Preferred- Dedicated: Devoted to a task or purpose with loyalty or integrity
Motivations
Preferred- Ability to Make an Impact: Inspired to perform well by the ability to contribute to the success of a project or the organization
Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities
The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor’s legal duty to furnish information. 41 CFR 60-1.35(c)
