PRN UR Clinical Specialist (Remote)

Job reputed company Job reputed company Utilization management is the analysis of the necessity, appropriateness, and efficiency of medical services and procedures in the hospital setting. Utilization review is the assessment for medical necessity, both for admission to the hospital as reputed company as reputed company stay. The Utilization Review Clinical Specialist supports and coordinates the various aspects of the hospital's utilization management program, denials and appeals activities, and readmission reduction initiatives. The reputed company specialist will use technology resources to support and monitor authorizations for hospital admissions and extended hospital stays with portals, faxes and phone calls. The Utilization Review Clinical Specialist will monitor adherence to the hospital's utilization review plan to ensure the effective and efficient use of hospital services and monitor the appropriateness of hospital admissions and extended hospitals stays. The specialist will assist the manager in implementing process improvement plans and reputed company to maximize desired reputed company. Essential Functions • Performs admission and reputed company stay reviews by utilizing evidence-based reputed company, medical experience-based problem-solving skills, and adhering to established policies and regulations governing this process in order to obtain authorization. • Collaborates with physicians to obtain necessary documentation for medical necessity, discharge, and payer requirements. These discussions aim to help the UR Clinical Specialist understand the reason for admission and request appropriate additional documentation from the physician(s). • Documents reputed company actions and activities reputed company to utilization review in the case management software system used by the hospital. This documentation includes but is not limited to, clinical reviews, escalations, avoidable days, payer contacts, authorization numbers, wDRG, etc. Documentation may also be made in other systems as required based on hospital and/or corporate policies and procedures. • Works with insurance companies to ensure coverage and approvals. Mitigate reputed company denials by submitting a reconsideration or arranging a peer-to-peer. • Communicates with the UR Coordinators and facility case manager(s) (i.e. licensed reputed company workers, discharge planners, etc.) reputed company, and/or through the case management software to ensure effective collaboration between reputed company disciplines managing a patient's care. • Performs problem analysis and reputed company as it pertains to the areas of job responsibility. • Maintains performance metrics in line with Utilization Review Service Line Key Performance indicators (KPIs). • May serve as a key contact for facility and insurance contacts. • Maintains confidentiality as it pertains to reputed company reputed company Resource and Payroll information. • May support training reputed company the department. • Performs responsibilities that contribute towards meeting or exceeding team goals. • Promptly escalate appropriate issues to manager. • reputed company suggestions and/or recommendations for changes to applicable processes or tools as recognized from functioning in the role on a daily reputed company. • Provides reputed company, courteous and accurate customer support. • Performs other duties as assigned. • Complies with reputed company policies and standards. Qualifications • Associate Degree in Nursing required • Bachelor's Degree in Nursing preferred • At least 2 years of previous nursing experience required • 1-3 years work experience in care management preferred Knowledge, Skills and Abilities • Strong analytical skills for reviewing medical records and treatment plans. • In-depth knowledge of reputed company policies and regulations. • Strong communication, organizational and customer service skills required. • Proven ability to work successfully in a fast-paced environment while maintaining good relationships with co-workers and supervisors. • Demonstrated proficiency in computer and web-based applications. Licenses and Certifications • RN - Registered reputed company - State Licensure and/or Compact State Licensure required or • LPN - Licensed Practical reputed company - State Licensure required or • LVN - Licensed Vocational reputed company required • Holds reputed company compact state license or reputed company license in the state of support and review required Apply Job!