Quality Utilization Specialist Full-time, Days, Hybrid ($4,000 sign-on bonus)
Core
Registered nurse specializing in hospital utilization review, medical necessity screening, and cost-effective care assignment for inpatients.
Role type
Senior IC utilization review nurse
Builds
Hospital health care benefit coverage decisions and appropriate level of care assignments
Domain
Healthcare / Hospital Operations
Required skills
Medical necessity screening, level of care guidelines application, patient care plan collaboration, data analysis, regulatory compliance, interdisciplinary communication, performance improvement, conflict management, educational program development
Preferred skills
Change management, financial indicator reporting, audit follow-up, quality tool development
Technologies
Data reporting tools, spreadsheets, word processing
Responsibilities
Completes initial and continuing stay reviews for hospitalized patients; applies medical necessity criteria to ensure appropriate admissions and length of stay; collaborates with clinicians and payors on care decisions; monitors utilization data trends; participates in clinical performance improvement initiatives; develops and presents utilization education programs; assists in appeals for insurance denials.
Seniority
Senior, hands-on IC