Utilization Review Specialist

Overview Reviews clinical information and supporting documentation for outpatient or Part B services to determine appeal action. Reports to the manager of the Denial Mitigation Department. Performs other duties as assigned. Responsibilities Reviews, assesses, and evaluates all communications received in order to optimize reimbursement. Evaluates clinical information and supportive documentation prior to initial appeal action in order to optimize reimbursement and utilization of resources. Prepares response to appeal/request for information based on supporting clinical information in order to enhance reimbursement and maximize customer satisfaction. Compiles, analyzes, and distributes necessary clinical and financial information and presents reports to other healthcare providers in order to improve performances, and increase awareness of resources consumed related to reimbursement. Completes assigned goals. Education Minimum: Ability to type and/or key accurately and have strong organizational skills. Experience Preferred: 3 years clinical experience and at least 3 years payer experience. Minimum: 2-5 years clinical experience in a clinical care setting. Licensure, Registration, Certification Preferred: RHIT; LPN;RN Special Skills Minimum: Excellent communication skills. Advanced computer literacy skills with the ability to type and key accurately. Training Minimum: Requires critical thinking and judgement and must demonstrates the ability to appropriately use standard criteria established by payers. #J-18808-Ljbffr