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