Position Summary
The Utilization Review Specialist will ensure regulatory compliance with CMS Conditions of Participation with regard to Utilization Management. Perform Utiliztion Review according to CMS and commercial payor guidelines. Participate in denial / appeal process.
Responsibilities
- Utilization Management. Utilizes the nursing process to assess, plan, implement and evaluate the utilization management needs for patients in assigned caseload. Performs utilization management activities using approved screening criteria.
- Provides follow up with appropriate resource for utilization management issues/non-compliance.
- Clinical Progression and Utilization Management. Participates in quality improvement (QI) activities.
- Advances knowledge and skills in case / utilization management.
- Collaborates effectively with departmental staff to achieve goals and objectives.
Minimum Requirements
Associates Degree in Nursing or higher required. NC RN licensure required.
If ADN must have 5 + years experience in an acute care hospital; home health agency; commercial insurance company; case management.
If BSN must have 3-5 years experience in an acute care hospital; home health agency; commercial insurance company; case management.
A certification in Case Management (i.e. CCM, ACM) can substitute for 1 year of experience; Masters Degree in health related field can substitute for 1 year of experience.
Pay Range
$65520.00 - $95501.12
ECU Health
