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Utilization Review Specialist
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Job Description
- Performs preadmission review on admissions when required by insurance companies/agencies to comply with policies and procedures.
- Works in coordination with discharge planner, monitoring medical necessity for admissions and appropriate level of services.
- May also need to notify physician and patient of authorization denials.
- Inputs collected data into computer system for insurance communication.
- Assists with retrospective review of specified charts as required.
- Obtains extensions in length of stays from insurance companies if needed.
- Obtains preauthorization and/or precertification of services.
- Reviews hospital records daily to determine if utilization resources could be served in a better environment, OBS vs INPT.
- Ability to interact on an interpersonal basis with providers and other staff within the organization.
- Education: Appropriate education level required in according with licensure.
- Experience: Three years of relevant experience with superior communication and interpersonal skills. Minimum one year healthcare or clinical experience required.
- License Requirements: Licensed Practical Nurse (LPN) license with State Nursing Board and/or possess multistate licensure privileges or a Registered Health Information Technician (RHIT) required. Additional coding certifications also acceptable such as certified coding specialist (CCS), certified coding specialist physician (CCS-P), certified professional coder (CPC) and certified professional coder – hospital (CPC-H).
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