Utilization Review Specialist

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 Other Information Shift: Monday- Friday. Day shift with alternate holiday rotation On-site EEO Statement We value diversity and are proud to be an equal opportunity employer. Decisions of employment are made based on business needs, job requirements and applicant’s qualifications without regard to race, color, religion, gender, national origin, disability status, protected veteran status, genetic information and testing, family and medical leave, sexual orientation, gender identity or expression or any other status protected by law. We prohibit retaliation against individuals who bring forth any complaint, orally or in writing, to the employer, or against any individuals who assist or participate in the investigation of any complaint. #J-18808-Ljbffr ECU Health