Quality Utilization Specialist Full-time, Days, Hybrid ($4,000 sign-on bonus)
Core
Conducts utilization reviews and audits for hospitalized patients to ensure appropriate level of care, medical necessity, and cost-effective health care services.
Role type
Senior Registered Nurse - Quality Utilization Specialist
Builds
Hospital health care benefit coverage decisions and optimized utilization practices
Domain
Healthcare / Hospital Operations / Utilization Management
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Acute inpatient nursing expertise, medical necessity screening, data analysis, regulatory compliance, interdisciplinary collaboration, performance improvement, conflict management
Preferred skills
Change management, stakeholder education, financial indicator reporting, audit follow-up
Technologies
Data reporting tools, spreadsheets, word processing
Responsibilities
Apply medical necessity criteria to determine admission and length of stay; complete initial and continuing stay reviews for hospitalized patients; collaborate with clinicians and payors on care plans and coverage; monitor utilization data trends and report metrics; participate in clinical performance improvement initiatives; assist in appeals for insurance denials.
Seniority
Senior, hands-on IC