Utilization Review Specialist

The Utilization Review Specialist is responsible for the assessment and review of the healthcare delivery system with a concentration on tasks that promote cost-effective quality care and cost containment in accordance with various federal and/or state statutes, regulations and guidelines as well as facility policy.

Essential Duties and Responsibilities:

• Performs utilization review in accordance with all state mandated regulations
• Analyzes insurance, governmental and accrediting standards to determine criteria concerning admissions, treatment, and length of stay
• Assures compliance with state and federal regulations and billing requirements
• Maintains compliance with regulation changes affecting utilization management
• Reviews patient records and evaluates patient progress
• Ensures high standard of patient care by establishing best practice benchmarks
• Obtains and reviews necessary medical reports and related treatment plan to conduct review
• Reviews and validates physician's orders, reports progress, and unusual occurrences on patients
• Ensures appropriate and cost-effective healthcare services to patients.
• Analyzes patient records and participates in interdisciplinary collaboration with professional staff
• Facilitates educational programs as directed to keep physicians and professional staff informed about regulations affecting utilization management
• Recognizes and reports appropriately cases of fraud, abuse or incorrect utilization
• Consults with Social Services Department regarding the level of nursing care and collaborates with other departments in evaluation of projects affecting discharge plans
• Supports performance improvement programs
• Performs continuing review on medical records and identifies and evaluates need of ongoing hospitalization and services

Minimum Requirements:

• Current license for the state in which the nurse practices if nursing licensure is required by contract
• A Bachelor's Degree in Nursing or at least two years' experience in Utilization Review preferred
• Certification in Utilization Review or Utilization Management preferred
• Experience with Microsoft Office Suite and the ability to learn new information systems and software programs
• Strong problem solving, project management and organizational skills with an ability to work in a fast paced environment
• General knowledge of managed care delivery system
• Complies with all relevant professional standards of practice
• Participation and completion of Amergis' Competency program when applicable
• Current CPR if applicable
• TB questionnaire, PPD or chest x-ray if applicable
• Current Health certificate (per contract or state regulation)
• Must meet all federal, state and local requirements
• Successful completion of new hire training as applicable to job site
• Understand patient confidentiality and HIPAA requirements
• Ability to effectively elicit/provide information to and from appropriate individuals (including, but not limited to, supervisors, co-workers, clients) via strong communication skills; proficiency in the English language is required
• Computer proficiency required
• Must be at least 18 years of age

Benefits At Amergis, we firmly believe that our employees are the heartbeat of our organization and we are happy to offer the following benefits:

• Competitive pay & weekly paychecks
• Health, dental, vision, and life insurance
• 401(k) savings plan
• Awards and recognition programs

Amergis, formerly known as Maxim Healthcare Staffing, has served our clients and communities by connecting people to the work that matters since 1988. We provide meaningful opportunities to our extensive network of healthcare and school-based professionals, ready to work in any hospital, government facility, or school. Through partnership and innovation, Amergis creates unmatched staffing experiences to deliver the best workforce solutions. Amergis is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to sex, gender identity, sexual orientation, race, color, religion, national origin, disability, protected Veteran status, age, or any other characteristic protected by law.